Membership Form · Louisiana Academy of Sciences

For the Calendar Year __________

Check the appropriate box: 	  New member	  Renewal

Select one section affiliation:

Agriculture, Forestry, & Wildlife Division	Biological Sciences Division
  Agriculture, Forestry, & Wildlife Section	  Botany Section
		  Environmental Science Section
Physical Sciences Division	  Microbiology Section
  Chemistry Section	  Molecular & Biomedical Biology Section
  Computer Science Section	  Zoology Section
  Earth Sciences Section			
  Materials Science & Engineering Section	Science Education Division
  Mathematics & Statistics Section	  K-12 Education Section	
  Physics Section	  Higher Education Section

Social Sciences Division
  Social Sciences Section

	Date:

  Dr.
  Mr.
  Ms.
  Other	First name: 	M.I.	
	Last name:	
     _____	Address:	

	City: 	State:	
	Zip code: 	Telephone:	
	E-mail:	
	Institutional affiliation (if different from above):	

Select one Membership Classification:

  Regular	$30.00	  Business	$100.00
  Student	$10.00	  University/College	$100.00
  Emeritus	$0.00	  Corporate	$200.00
  Patron	$30.00	  Corporate Sustaining	$350.00
		  Corporate Benefactor	$500.00

Submit to Membership Secretary: Dr. Elisabeth Elder · Department of Biological Sciences · Louisiana State University at Alexandria · 8100 Hwy 71 South · Alexandria, LA 71115