STUDENT MEMBERSHIP APPLICATION

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STUDENT INFORMATION Please Print Clearly Bolded Items Are REQUIRED

Prefix: First Name: Middle Initial: Last Name:

Informal Name: Gender: Female Male Age Range: 25 and under 26 35 36 45 46 55

56 65 66 and above
University/College: Expected Date of Graduation:

Fields of Study: Chemical Engineering Mechanical Engineering Engineering Other Pharmacy Life Sciences (e.g. Biology, Chemistry)
Business Other: ___________________________________________________________
PRIMARY CONTACT INFORMATION
Home School
Street Address:

P.O. Box: Apartment/Suite/Mail Stop:

City or Suburb: State / Province: Zip+4 / Postcode:

Country: Telephone: Fax:

Email Address: Mobile:

ALTERNATE CONTACT INFORMATION

Home School
Street Address:

P.O. Box: Apartment/Suite/Mail Stop:

City or Suburb: State / Province: Zip+4 / Postcode:

Country: Telephone: Fax:

Email address: (Help us keep in touch with you no matter where you are) Alma Mater:

MEMBERSHIP CATEGORIES* AND PAYMENT INFORMATION

All Members of ISPE are entitled to vote on matters pending before the Society, hold office, and serve on committees. Memberships are individual and not
transferable. For membership category descriptions and bylaws, visit www.ISPE.org/Join.

Student Members: Individuals enrolled full-time at a college, university, or other educational

institution. Parttime students are eligible if your primary concentration is education, such as a Send by Mail or Fax:
combination of class work and an internship. Documentation of enrollment must be received within 10 ISPE Headquarters
business days of joining in order to retain active membership. *See reverse for approved forms of 600 North Westshore Blvd, Suite 900
documentation. Questions? Contact Member Services at ask@ispe.org. Tampa, FL 33609-1114 USA
$20 / 20
Tel: +1-813-960-2105 Fax: +1-813-264-2816
Emerging Economy Students: Individual students residing in an emerging economy country receive Email: ask@ispe.org
discounted dues. For a list of eligible countries, please visit www.ispe.org/emerging-economy-countries.
Your dues must be remitted directly to the local Affiliate/Chapter. To contact your local Affiliate/Chapter, China Office
please visit www.ISPE.org/affiliates_chapters. If you attend a school outside the geographic region of an
Affiliate/Chapter, please remit your dues to the ISPE Office located nearest you. Level 4, Puxi Management Center
$5 / 5 No. 801 Jumen Road, Shanghai 200023, China
Tel: +86-21-2312 3640 Fax: +86-21-2312 3699
*Contact Member Services for assistance in changing Membership Categories. Email: china@ispe.org

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LOCAL AFFILIATES / CHAPTERS (select one)
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 STUDENT MEMBERSHIP APPLICATION
Join online at www.ISPE.org/Join
Full Name __________________________

www.ISPE.org/Affiliates_Chapterswww.ISPE.org/Affiliates_Chapters for more information.

Argentina Spain I do not elect Affiliate/Chapter membership

Australasia (select one Chapter) Thailand
Adelaide Turkey There is not an Affiliate/Chapter in my area
Brisbane United Kingdom (select one Region)
Melbourne Central
New Zealand North East
Sydney North West
Belgium Southern
Brazil United States (select one Chapter)
Central Canada Boston Area (Massachusetts, Maine, New Hampshire, Rhode Island, Vermont, Connecticut, Upstate New York)
China (under development) Carolina-South Atlantic (North and South Carolina, Georgia, Florida, Alabama, and Tennessee)
Czech Republic/Slovakia
Chesapeake Bay Area (Maryland, Washington DC, and Northern Virginia)
France
Germany/Austria/Switzerland Delaware Valley (Eastern Pennsylvania, Southern New Jersey, and Delaware)
India Great Lakes (Ohio, Indiana, Illinois, Michigan, Wisconsin, and Kentucky)
Ahmedabad Greater Los Angeles Area (Los Angeles, Orange, Ventura, and Riverside Counties)
Bangalore Midwest (Missouri, Kansas, Nebraska, Iowa, and Minnesota)
Hyderabad
New Jersey (New Jersey, New York, and Northeastern Pennsylvania)
Indonesia
Ireland Pacific Northwest (Washington and Oregon)
Italy Rocky Mountain (Colorado and Utah)
Japan San Diego (San Diego North to South Orange County)
Korea, Republic of San Francisco/Bay Area (Northern California)
Malaysia
South Central (Texas, Oklahoma, and Louisiana)
The Netherlands
Nordic (Sweden, Denmark, Norway, Finland,
and Iceland)
Philippines
Poland
Singapore

I DO NOT WANT TO RECEIVE COMMUNICATIONS FROM:

ISPE International and regional offices

My ISPE Affiliate or Chapter (see above)
I wish to keep my data confidential (This will exclude you from the Conference Attendee Listing, Member Directory and Exhibitor List)

I hereby apply for ISPE membership and certify that all statements in this application are correct, and if elected to membership, agree to be
governed by the Society Bylaws, and the ISPE Codes of Conduct. www.ispe.org/codes-of-conduct

Applicants Signature:_________________________________________________________________Date:_____________________________

Application Checklist: Acceptable Proof:

Current semester schedule showing number of credits
Fully completed membership application Transcript (official or unofficial) with number of credits
Payment Valid and current student ID
Proof of student status University letter stating student
University Web site page stating the date
12/16