IEIIS MEMBERSHIP

First Name*

Middle Initial

Last Name*

Prefered Name

Highest Degree(s)*

Phone*

Fax

Email*

Information gathered through this site is considered private and is for the exclusive use of the IEIIS in conducting its internal business. Your information will not be shared with any Third Party without your express permission (below).

Exact mailing address is required for mailing of IEIIS membership card.

Institution/Department*

Address 1*

Address 2

City*

State/Province*

Zip*

Country*

Membership

        New Membership

If you are a new Student member, please provide name of Supervisor or Professor

Change in Membership Status?

Membership Choice:*

If Active Membership Was Chosen

        STUDENT #1: Name, Degree

                STUDENT #1: Full Mailing Address (member card to be mailed)

                STUDENT #1: Phone

                STUDENT #1: Email

        STUDENT #2: Name, Degree

                STUDENT #2: Full Mailing Address (member card to be mailed)

                STUDENT #2: Phone

                STUDENT #2: Email

Would you like to be considered for an elected or appointed office in the IEIIS? -- Pick One -- Yes No

Are you interested in receiving information about products or services of possible interest to those in the endotoxin and innate immunity fields? -- Pick One -- Yes No

If name on credit card is not the person on this form, please note cardholder`s name here