HEALTH SCIENCES WOMEN'S FACULTY ASSOCIATION

MEMBERSHIP FORM

Academic Year 2002-2003

Please complete the form and make check payable to:

Health Sciences Women's Faculty Association

Mail to: Janis Brown, HSWFA Membership Chair
Norris Medical Library, University of Southern California, Los Angeles CA 90089-9130

Name:

Title:

Department:

Campus Address:

Home Address:

Campus phone:

Home phone:

Campus fax:

Home fax:

Campus Email:

Home Email:

Send mail to: ______campus (cost saving)

                         ______home

Are you willing to serve on HSFWA committees? (Check areas of interest)

_____Professional Development                           ____ Program

_____Student Liaison                                           _____ Membership

_____Newsletter                                                  ____ Bylaws

Member status: ______New Member          _____Continuing Member

Check here if you do not wish to be listed on the Members web page _____

Membership Categories:

____Regular Faculty ($30)            _____Voluntary Faculty ($15)

____Retired Faculty (none)           _____Associate ($15)-check position below:

                                                               ____Post-doc Research Associate
                                                               ____Medical Resident

Research Area:

Donations: (make checks payable to Health Sciences Faculty Women’s Association)

_____Student Professional Development         _____General Discretionary funds

Additional membership recommendations
(Colleagues who may not currently be members)

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Address
Phone number

Name
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Phone number

Name
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Phone number