1. PERSONAL INFORMATION

Name (Prof., Dr., Mr., Ms.)

E-mail

Home Address:

Address

City

ZIP

Phone

Business Address:

Address

City

ZIP

Phone

Please, indicate the preferred mailing address:
Home Address
Business Address

Birth Date

Citizenship

ANS Membership:
Member
Associate
Student*
Non-ANS Member*

* Non-ANS - Members or ANS Student Members will become respectively Participant Member or Student Member of the Section with full right to participate in all activities of the Section; however, they will not have voting rights nor will they be able to hold executive positions.

Dues (For individual members):

US$ 10.00 / R$ *
Fiscal Year: 2007-2008

*Annual dues, in US$ or R$, should be sent together with the answer of this form. Please make checks to the order of LATIN AMERICAN SECTION OF ANS. Payment in R$ shall be based on the official rate of exchange on the day of payment.

2. EDUCATION

UNIVERSITY	MAJOR	DATE CONCLUSION	DEGREE RECEIVED

3. PROFESSIONAL EXPERIENCE

Provide sufficient detail so that the relevance of your experience to nuclear science and engineering can be determined.

Present Employer
From to

Address

ZIP, Country

Title

Yr. Duties & Responsibilities

Previous Employer
From to

Address

ZIP, Country

Title

Yr. Duties & Responsibilities

4. REFERENCES

Please indicate two Section members or any professional in your area of activity (not necessarily a member) who are acquainted with your professional experience. The Membership Committee Chairman will contact them directly.

FIRST:

Name

Address

Phone

Fax

E-mail

SECOND:

Name

Address

Phone

Fax

E-mail