REGISTRATION/MEMBERSHIP RENEWAL FORM

TENNESSEE ACADEMY OF SCIENCE

ANNUAL MEETING

University of Tennessee at Martin, Boling University Center, Martin, TN

Friday, November 17, 2017

Please Print Legibly and mail to: Dr. Steve Murphree, TAS Treasurer, Department of Biology, Belmont University, 1900 Belmont Blvd., Nashville, TN 37212-3757

Name: Date:

Mailing Address:

City: State: Zip:

Phone: Fax:

E-mail:

Registration Fee: $25.00 ($5.00 for students)

Please send me a Disability Parking Pass and directions to the designated parking area

Box Lunch & Drink Tickets: @ $12.00 each

I request a: Turkey & cheddar on a Kaiser roll Ham & swiss on a Hoagie roll

Fajita Bar & Drink Tickets: @ $17.00 each

(Vegetarian option)

Please check appropriate membership:

Regular $40 Sustaining $50 Emeritus $10

Supporting $100 Student $10 Life $400 (a single payment)

Membership Fee (Jan. 1, 2018 through Dec. 31, 2018)

Total (make check payable to “Tennessee Academy of Science”)

Please indicate your scientific discipline or interest (check maximum of five):

Agriculture Astronomy Botany

Cell and Molecular Biology Chemistry Ecology and Environmental Science

Engineering and Engineering Technology Geology and Geography Health and Medical Science

History of Science Mathematics/Computer Science Microbiology

Physics Science and Math Teaching Zoology

Members receive the Journal of the Tennessee Academy of Science. All papers and posters presented at meetings of the Academy must be authored or co-authored by a member of the Academy.

I am I am not available to serve as a judge for science fairs in my area.

I am I am not available to participate in the TAS NETWORKS PROGRAM as a Networks Scientist available via email to K-12 students across Tennessee.

I do I do not agree to allow the information given above to be posted on the TAS website (http://www.tennacadofsci.org ). Please note: We cannot inform others that you are willing to serve as a science fair judge or in the Networks program if you do not check “I do.”

Signature:

THIS FORM MUST BE POSTMARKED BY MONDAY, NOVEMBER 13th
PLEASE DO NOT BRING A COMPLETED FORM TO THE ANNUAL MEETING IF YOU WANT A RECEIPT; RATHER, REGISTER AT THE MEETING TO RECEIVE A RECEIPT