Membership Form



Please send to: Dr. Charles E. Ribak
                Secretary/Treasurer of Cajal Club
                Department of Anatomy & Neurobiology
                University of California at Irvine
                School of Medicine
                Irvine, CA 92697-1275 USA

Please complete and return with  your Membership Fee.

NAME

ADDRESS


CITY/STATE/ZIP

EMAIL

FAX

MEMBERS RESIDING OUTSIDE USA SHOULD MAKE PAYMENT IN US DOLLARS ONLY. 
We cannot accept credit card payments.

MEMBERSHIP FEE (Please check one or more)

___  Active Member ..............$30.00

___  Student/Postdoc Member ....$10.00

___ Retired Member .............$0


Please make checks payable to: CAJAL CLUB


ANNUAL DUES FOR 2008-2009 

Please complete and return with 2008-2009 Cajal Club annual membership dues.

NAME

ADDRESS



CITY/STATE/ZIP

EMAIL

FAX


MEMBERS RESIDING OUTSIDE USA SHOULD MAKE
PAYMENT IN U.S. DOLLARS DRAWN ON A U.S. BANK.
We cannot accept credit cards for Cajal Club dues payments

MEMBERSHIP DUES
(PLEASE CHECK ONE)

___ Active Member ………………………….$30.00

___ Student/Postdoc Member…………….$10.00

___ Retired Member……………………..…$0

TAX EXEMPT DONATIONS

___ Donations for support of student activities
       (i.e., travel grants, poster prizes, etc.)
Please indicate whether you want a pin (they are in limited supply).


Please make checks payable to:  Cajal Club

Please return completed form with your check to:

Charles E. Ribak, Ph.D.
Cajal Club, Office of the Secretary/Treasurer
Department of Anatomy & Neurobiology
University of California at Irvine
Irvine, CA 92697-1275