ACSE Application Form

Name _______________________ Chinese Name: ___________________________

Spouse (if applicable)
Name _______________________ Chinese Name: ___________________________

Address
______________________________________________________________
City___________________ State _____________ Zip __________________

Affiliation ___________________________

Phone Numbers: Home _____________________ Work: _____________________

Email ______________________________________________________________

Highest Degree Earned ___________________ Major _________________________

The annual membership fee for regular member is $15 per person, and $20 per married couple. The annual membership fee for student member is $10, and $15 per married couple.

Please print this form and send the form to the following address, along with the check payable to ACSE, Phoenix.

Association of Chinese Scientists and Engineers, Phoenix Chapter

611 E Fairivew St. Gilbert, AZ 85295