Date________________
Organization____________________________________________________________
Mailing Address: _______________________________________________________
Contact: _______________________________________________________________
Phone Number: _________________________ FAX: ___________________________
Email Address: ______________________________________
Web Site Address: ___________________________________
Membership in the National Health Physics Society:
_____None _____Class A _____Class B _____Class C _____Class D
In the space below (and on another sheet of paper, as needed), provide a brief resume of your organizations radiation protection activities. Also, please include any pertinent literature as background information. If enclosing product brochures, please include eight copies.
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Application submitted by:
________________________________
Name
________________________________
Title
________________________________
Date
Mail completed form and Membership Dues to:
East Tennessee Chapter of
Health Physics Society
Attn: Secretary
P.O. Box 7006
Oak Ridge, Tennessee 37831-7006
AFFLIATE MEMBERSHIP
Annual affiliate dues are $75.00.
Affiliates receive the following:
1. Monthly Electronic ETCHPS Newsletter
2. A discount of $75.00 for a booth at the Annual ETCHPS Vendors Meeting
3. Link on the ETCHPS Web Page
4. The option of sponsoring ETCHPS activities
A check for $75.00 must accompany this form, made in US Dollars, drawn on US banks, made payable to the ETCHPS.
