International Liquid Crystal Society
Membership Application Form

Member Information First Name Surname National Affiliation Address Line 1 Address Line 2 Address Line 3 Town State/Province Postal Code Country Phone Number FAX Number Email Address Interests Highest Degree BSc BS MSc MS PhD DSc Other None Year Obtained Degree Awarded by Dues and Contributions Member Category Full Member Dues $25 Associate Member Dues $15 Affiliate Society Member Dues $25 Affiliate Society Member Dues (2 years) $50 Student Member Dues $10 Sustaining Member (businesses only) Dues $100 Lifetime Membership Dues $312 Annual Membership, Developing Countries Dues $5 Lifetime Membership, Developing Countries Dues $62 Voluntary Contribution to ILCS Awards and Prizes Fund $ Payment Information Method of Payment By Check Credit Card Credit Card Type Master Card Visa Credit Card Number                   Expiration Date     Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2008 2009 2010 2011 2012 2013 2014