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ALL MUSLIM ASSOCIATION FOR ADVANCEMENT OF SCIENCE- USA

Tel: 870-534-4522; E-mail: [email protected]

"Knowledge is Power"

MEMBERSHIP APPLICATION

 NAME (Last)<(First)(Middle)

MAILING ADDRESS: (street)

(City)(State)(Zip)(Country)

TELEPHONE: (Home)(Work)

FAX: 5. E-MAIL:

NATIONALITY: 7. COUNTRY OF BIRTH:

HIGHEST EDUCATION: 9. PROFESSION:

PROFESSIONAL AFFILIATION:

ACADEMIC INTERESTS & PUBLICATIONS: (optional; include C.V. if possible):

I AGREE WITH THE FOLLOWING:

I have read the mission statement. To the best of my abilities, I shall be actively involved in the organization of local, regional and/or national chapters of All Muslim Association for Advancement of Science to promote its goals.

. DUES AND CONTRIBUTION:

My Annual dues of $25 is enclosed ...

Additional contribution will be appreciated. …

Total enclosed:

. WE WOULD LIKE TO INVITE YOUR FRIENDS TO JOIN AMAAS. PLEASE PROVIDE

INFORMATION. (For additional information, use back of paper)

: Address:

Tel: Professional affiliation:

: Address:

Tel: Professional affiliation:

SIGNATURE & DATE: