Membership Application Form

Australian Society for Biophysics

Title:
Surname:
First Name:
Position in Department:
Department:

Institution:
Street/PO Box:
State:
Postcode:
Country:
Phone:
Fax:
Email:
Areas of Research (up to three broad categories)
1:
2:
3:

Membership in the Australian Society for Biophysics is open to scientists who share the purpose of the Society and who have educational or research experience or interest in biophysics or in an allied scientific field. The purpose of the Australian Society for Biophysics is to encourage development and dissemination of knowledge in biophysics. I share the purpose of the Society and apply for Membership. I have been nominated by a member of the Society who has signed below.

Signature of Applicant:
Date:
Name of Nominator/Supervisor:
Signature:
Membership Type:	Annual Membership, $45 Five Year Membership, $200 Annual Student/Retiree Membership, $20 Three Year Student/Retiree Membership, $50
Your total is $

Please indicate your method of payment:

Bank Transfer

Account Name:	Australian Society for Biophysics
Bank:	Commonwealth
BSB:	063238
Account Number:	10195555

Please put in the comment field to identify your payment.

Cheque/Money order

Please make payable to "Australian Society for Biophysics" and post to the address below.

Visa
Mastercard

Card Name:
Card Number:
Card Expiry:
Signature:
We cannot process secure online payments at this time. Please print this page and fill in your credit card details and send or fax it to the address below.

When you are finished, as we require signatures, you will need to print and return this application to:

If you have any comments or suggestions about the web page please email web@biophysics.org.au

Last updated on 19/09/2007