CSA MEMBERSHIP APPLICATION

Click here to download the application form in pdf format
Click here to download the application form in doc format

       Please check: New  Or  Renewal

       Type of membership: (Please check): Regular ($25)       Lifetime ($200)     Associate ($10)

       1. Name (English): ______________________________

       2. Chinese  Name: ______________________________

       3. Affiliation and Title (University/organization)

       ______________________________________________________________________

       4. Academic qualification, including year of degree awarded and name of universities:
_____________________________________________________________________

       Year of Ph.D., or equivalent  earned: _________________________________________

       5. Office Address: ______________________________________________________

       6. Email: __________________________ Website: _____________________________

       7. Phone:  ______________________ Fax: ____________________________

       8. Home Address (optional) :________________________________________

           City and Zip: _______________________________

       9. Past Employment (optional): Year: _______________   Job Title: ________________

       Institution: __________________     Address: __________________________________
__________________________________________________________________________

10. I am interested to get involved in: (Please check as many as apply)
___ Annual assembly and spring gathering	___Social gatherings, open house
___Forums, symposium, seminars	___China tour (conference, lectures, visit)
___Publications	___Webmaster
___Social science committee	___Science & Engineering committee
___Outreach activities	___Fundraising

Please fill out the membership application form above and mail it with check to:

Dr. Ren Sun, CSA Treasurer

Department of Molecular and Medical Pharmacology

David Geffen School of Medicine at UCLA

Mail box 951735, CHS 23-120, Los Angeles, CA 90095-1735