PO Box 14274 Durham, NC 27709
Contact:NCHPS President-Elect Jonathan Moore
Membership Application and Renewal Online
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1. Complete the application below. If you are not a member of the Health Physics Society, signatures of two members in good standing of the chapter are required. 2. New membership dues paid after September 1 will apply through the following year. Chapter Dues: $ 15.00/year Student/Science Teacher Dues: $ 5.00/year Affiliate Dues: $ 40.00/year Make check payable to the North Carolina Health Physics Society. Send the completed application and dues to the Membership Committee Chairperson: North Carolina Health Physics Society PO Box 37638 Raleigh, NC 27627 |
Affiliate membership in the NCHPS is limited to organizations having a professional interest in the general field of radiation protection. This class of membership offers the following privileges to an organization: § Acknowledgement in each issue of the Chapter Newsletter and in the Chapter Directory.§ One year regular membership for an individual from the organization.§ Receipt of all official Chapter mailings (including the Chapter Newsletter).§ Access to and commercial use of the Chapter Membership Directory.§ $50.00 off normal exhibitor fees to display products/services at NCHPS chapter meetings. |
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Name: ____________________________________________ __________________________________________________ Address Line 1 __________________________________________________ Address Line 2 __________________________________________________ Address Line 3 _____________________________ ________ __________ City State Zip Education (Institution, major field, degree, and date): __________________________________________________ Are you a Health Physics Society member? ( ) Yes ( ) No Professional Certifications (CHP, CSP, CIH, etc.):__________ Applying for: ( ) Chapter Membership ( ) Student Membership ( ) Science Teacher mailing list ( ) Affiliate Membership |
Company/School: _________________ Business Phone: __________________ FAX: ___________________ Home Phone: ________________ E-mail: ________________________ ________________________________ Signature & Date ________________________________ Sponsor's Signature ________________________________ Sponsor's Signature |
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FOR CHAPTER USE ONLY: Application Received: ___________ Application Reviewed: ___________ Approved: ( ) Yes ( ) No New Member Packet Mailed: ________ Database Entry Complete: __________ |
Executive Council Approval (if not HPS member) Council Member: ________________________ Council Member: ________________________ Council Member: ________________________ Council Member: ________________________ |
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