Conference Program - ABRF 2011 - Association of Biomolecular ...

Membership ApplicationAssociation of Biomolecular Resource Facilities9650 Rockville Pike, Bethesda, MD 20814-3998 (USA)Telephone: (301) 634-7306 Fax: (301) 634-7455 Email: abrf@abrf.orgContact InformationYour NameCompany/InstitutionAddressCity State Zip CountryPhoneEmailFaxReferring ABRF Member NameImportant! Your membership confirmation will be sent via e-mail, along with other ABRF communications.Membership OptionsPlease check one: Member, $100.00 Student Member*, $35.00*To qualify for Student membership you must be a full-time undergraduate, graduate or medical student. Your department chair orstudent advisor must complete the following information:I certify that the applicant is a full-time student inEmail address of Department Chair/Major AdvisorSignature of Department Chair or Major AdvisorAdditional InformationAre you part of a resource laboratory? Yes NoIf yes, please list your director/manager’s name:Facility Name:Payment MethodPlease return this form with your full payment to assure proper credit. ABRF Tax ID: 56-1659510. Check enclosed for full amount made payable to ABRF. (Check must be in U.S. dollars and drawn on U.S. Bank.) Credit card (full amount will be charged): VISA MasterCard American ExpressMembershipApplicationCredit Card Number Expiration Date / /Signature of CardholderSend this form with payment to: ABRF, 9650 Rockville Pike, Bethesda, MD 20850-3998 (USA)Fax: (301) 634-7455 (Faxed membership forms must include credit card information.)128 • ABRF 2011 — Technologies to Enable Personalized Medicine