Print this form to mail with your check. Name:____________________________________ Date:________________ Title: ___CT ___SCT ___MD ___ Other - ____ Membership Type:___ Student($10)___Renewal($20) ___ Late Renewal(After 4/1, $25)___ New Member ($20) Additional tax deductible contribution (will go towards Jan Kramme Student Education fund): $________ Preferred E-mail Address: ________________________________________________ (Email communication is the fastest and least expensive method for the ISC) If paper mailings are still desired, please indicate preference: ___ Home ___ Work *Fill out the remaider only if you are a new member or if there are changes from last year: Home Address: Street______________________________Apt.______ City_____________________State_____ Zip ______ Phone _________________________________ Work Address: Employer:________________________________________ Street___________________________________________ City_____________________ State_____Zip __________ Phone_______________________________ Fax_________________________________ Membership year: Jan. 1 to Dec. 31. Student memberships run for the school year and are due by 9/15. Dues for a new member who joins mid-year are $10 Send your check payable to the Iowa Society of Cytology and with this completed membership form to: Mark Brown 1531 Langenberg Ave. Iowa City, IA 52240-9107