NES/OSA Application for Membership

Name:                

Signature:                                   

Date:                

Home Address:
                     

Telephone:           

Email:               

Business Address: 
                     

Telephone:           

Email:               

Preferred Mailing Address:         Home      Business

Preferred Phone for Annual List:   Home      Business   None

Position and title:                 

Education:                          

Previous Professional Positions:    

Chief Experience in Optics:         

Chief Fields of Interest in Optics: 

Member of National Optical Society of America?      Yes  No

Other Professional Societies:       

Would you be willing to assist in any of the following activities?

       Program Committee     Membership Committee
       Scholarship Committee
       Ad hoc Committee      Educators Committee
       Post meeting announcements in your company
       Enter No. of announcements

Annual Dues:            Regular  $15.00  Student   free


Send this application with a check made payable to NES/OSA to:


                             G. Groot Gregory

                             296 Lake Ave.

                             Newton  MA  02461