3M.council.membership.form

The 3M Council Executive is committed to protecting your privacy;
the personal information you are providing will be used for membership purposes only.

Section A:

Are you a 3M National Teaching Fellow?

Yes
No

Section B:

Last Name:

First Name:

Primary Occupation:

if Other, please specify

Contact Information:

Institution:

Institution Type:

if Other, please specify

Department:

Address:

City:

Province/State:

Country

Postal/Zip Code:

e.g. A1A 2A2

Business Telephone:

e.g. (xxx) xxx-xxxx

Extension:

Fax:

e.g. (xxx) xxx-xxxx

Email:

This field must be completed for proper acknowledgement.

Membership Fee: (Canadian Dollars)

Type	Amount
Regular Member	$70.00 plus 5% GST

Payment Type:

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