Please print out the form, fill it out, and send it with the membership fee to the below listed address.  Please print legibly!
ROCKY MOUNTAIN BRANCH-AMERICAN SOCIETY OF MICROBIOLOGY
MEMBERSHIP FORM






 Today's Date:__________________________________________________________

 Name:________________________________________________________________

 Degree:______________________________________________________________

 Title:_________________________________________________________________
 
 

EMPLOYMENT

Employer:_____________________________________________________

Street:________________________________________________________

City:_________________________________________________________

State:________________________________________________________

Zip code:_____________________________________________________

Work phone:___________________________________________________

FAX:________________________________________________________

 e-mail address:_________________________________________________
 
 
 

AMERICAN SOCIETY FOR MICROBIOLOGY

ASM regular or emeritus member.   ASM #:__________________________________________

ASM student member.                     ASM#:___________________________________________
 
 
 
 
 

MEMBERSHIP FEE

(         )    Regular membership in RMB-ASM    $15.00   (emeritus membership is free)

(         )    Student membership in RMB-ASM    $5.00
 

Checks should be made payable to : Rocky Mountain Branch-ASM
 

MAIL-IN ADDRESS:

Send the filled out form and check to:

Mark Gomelsky, Ph.D.
Associate Professor
MICRO/Dept. of Molecular Biology
Ag C Bldg., Rm. 6007
1000 E. University Ave., Dept. 3944
University of Wyoming, Laramie, WY  82071