The
New Zealand Institute of Physics Membership Application Form
Title
| Initials | Usual First Name | Family Name/Surname | Address for Correspondence (preferably
work)
|
| Phone | Fax | | E-mail Address | | Job Title | Employer | Brief Description
| | Qualification Name | Major Subject | Year Obtained | Awarding Institution |
| | | | |
| | | | |
| | | | |
| | | | |
| Experience (Teaching, Industrial, Technical,
Academic etc) | No of Years | | | |
| | |
| | |
| | |
I would like to apply for membership
of the New Zealand Institute of Physics at the status of:
¨Member
¨Associate Member (Education)
¨Student
¨Company
Signature..............................................................................................................
Date...............................................................
I enclose $............. (see the membership
information and regulations form for amount and conditions of membership).
Please tick if you are a Teacher
¨
Please return the completed form and cheque
to: Angela Fraser, Dept of Physics, University of Otago, 730 Cumberland
Street, Dunedin , New Zealand
| For
NZIP Use | For RSNZ Use |
| Membership Approved: | Membership
Number: | | Date: | Amount
Enclosed: | | Notifed: | Date
Processed: | |