Rubber Mini Expo - Rubber Division

Membership Form
Membership year runs from January 1 through December 31.
Membership Profile Your contact information, including e-mail will only be used for
limited Division mailings and will never be sold, traded or rented to any third party.
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Rubber Division Member # (if renewal)
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American Chemical Society Member # (if applicable)
Mr. Mrs. Ms. Dr. Male Female New Contact Information
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First Name
Last Name
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Email (required–confirmation & receipt are sent here)
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Company
Job Title
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Address
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Address
City
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State/Province Zip/Postal Code Country (if other than US)
_____________________________ _____________________________
Phone
Fax
Is the address above a home/home office address? Yes No
Would you like this information published in a Secure Online Members Only Membership Directory? Yes
No
PRIMARY BUSINESS FOCUS
(circle one only)
Manufacturer - Rubber or Plastics Product
01 Tires & Inner Tubes
02 Hose or Belting
03 Adhesives & Sealants
04 Footwear
05 Reclaimed/Recycled Rubber Products
06 Rubber Rollers
07 Fabricated Rubber Products
08 Wire or Cable
09 Other – Manufacturer (specify)
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Supplier
10 Automotive
11 Elastomers
12 Chemicals or Materials
13 Machinery or Equipment
14 Compounded Resin or Compounding
Services
15 Recycled Resin or Recycling Services
16 OEM User of Rubber Components
or Parts
17 Other – Supplier (specify)
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Miscellaneous
18 Consultant/Independent Research Lab
19 Government & Academia
20 Library
21 University/College or Academia
22 Association
23 Publication
24 Other – Miscellaneous (specify)
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JOB FUNCTIONS (circle all that apply)
101 Research & Development (Engineering
or Management)
102 Product Design (Engineering or
Management)
103 General or Corporate Management
104 Operations/Production
105 Administrative/Customer Support
106 Sales & Marketing
107 Purchasing
108 Testing/Quality Control
109 Workforce Training & Education
110 Student
111 Academic/Professor/Teacher
112 Press
113 Retired
114 Guest of Attendee
115 Other (specify)
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Selection Inside Outside Rubber Division Membership
U.S. U.S.
A $55 $70 New/Renew Membership
B $14 $14 Student Membership (Student ID or current class schedule required)
Selection Inside Outside RC&T Journal Choices
U.S. U.S. Rubber Chemistry and Technology is published 5 times a year between April and December.
Online subscriptions include access to all articles back to 1928.
A FREE FREE Online Member Subscription
Membership includes a subscription to the Rubber Chemistry and Technology journal online
B $350 $450 Printed Member Hardcopy Subscription (includes shipping)
Selection Inside Outside Rubber Group Memberships (Optional)
U.S. U.S. 100% of Rubber Group dues collected goes to the designated Rubber Group
A $40 $45 Rubber Recycling Topical Group
B $10 $10 Rubber Recycling Topical Group - Student
C $10 $10 Blue Ridge Rubber Group
D $10 $10 Chicago Rubber Group (Wisconsin and Central Illinois)
E $25 $25 Detroit Rubber Group
F $25 $25 Energy Rubber Group
G $40 $40 Los Angles Rubber Group
H $20 $20 MidAtlantic Rubber Group
I $10 $10 Midwestern Rubber Group
J $50 $50 Midwestern Rubber Group - Corporate
K $20 $20 New England Rubber Group
L $25 $25 Ohio Rubber Group
M $45 $45 Southern Rubber Group
N $10 $10 Twin Cities Rubber Group
O $10 $10 Western Michigan Rubber Group
P $15 $15 Western New York Rubber Group
TOTAL FOR MEMBERSHIP
Full Payment
MUST Accompany
This Form
REGISTER & PAY ONLINE: www.rubber.org OR BY FAX: (614) 448-4098
CREDIT CARD: (circle one) MasterCard Visa Discover AMEX
Credit Card Number 3 or 4-digit CVC # Cardholder’s Zip/ Postal Code
Exp. Date
Signature
CHECK PAYABLE TO: Rubber Division, ACS
MAIL TO:
Rubber Division, ACS,
c/o WALCOM
Registration Services
6780 Heverlo Road,
Sunbury, OH 43074
18 Rubber Mini Expo