PO Box 37638, Raleigh NC 27627
Contact: NCHPS President Giao Nguyen



Membership Application and Renewal Online

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Membership Application Print

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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.

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

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: ________________________