ASHRAE® NB/PEI Chapter

Membership Form

Form:

APPLICATION FOR ASHRAE® MEMBERSHIP

AMERICAN SOCIETY OF HEATING, REFRIGERATING AND AIR-CONDITIONING ENGINEERS, INC.
1791 Tullie Circle, N.E., Atlanta, GA 30329 U.S.A.
Telephone [404] 636-8400 [Worldwide]; [800] 527-4723 [U.S. and Canada Only] FAX [404]321-5478

Annual dues of $120 must accompany your application. Dues cover all services for one year. [Dues include U.S. $6 for ASHRAE Journal and is not deductible.]

______________________________________________________________
PAYMENT: May be made by check or credit card.
[If the applicant is not elected to membership, the fee will be returned.]

Checks - must be drawn in U.S. funds from U.S. banks. Canadian applicants may remit in U.S. funds from Canadian banks.
Credit Card - complete all information requested below:

[___] American Express [___] Mastercard [___] VISA

Credit Card No.___________________________________
Expiration Date___________________________________
Signature________________________________________
[Required for Credit Card Payment]

______________________________________________________________
1. I DESIRE: [___] admission as an ASHRAE member [___] reinstatement as an ASHRAE member
Previous Grade: [____________] Election Date: [____________] Member #: [____________]
[___] student advancement: Member # [_____________]

______________________________________________________________
2. Applicant:

[___] MISS [___]MS [___]MR [___] MRS

Name:____________________[First] ________________[Middle] ____________________[Family]

______________________________________________________________
3. I would like to participate in local activities of [ASHRAE Chapter name and number, if known]:

__________________________________ Chapter No______________

______________________________________________________________
4. HOME ADDRESS

_______________________________________________
Street Address

__________________________________________
Street Address

_______________________________________________
City

_______________________________________________
State/Province Zip/Postal

_______________________ / ______________________
County[U.S. only] Country

_______________________________________________
Home Phone [include Area Code]

______________________________________________________________
5. BUSINESS ADDRESS

_______________________________________________
Business Name

_______________________________________________
Subsidiary/Division/Dept.

_______________________________________________
Street Address

_______________________________________________
City

_______________________
State/Province Zip/Postal

___________________ / __________________________
County [U.S. Only] Country

_________________________________
Business Phone [Include Area Code]

_________________________________
Facsimile [Include Area Code]

_________________________________
E-Mail
___________________________________________________________________
6. Check Preferred:

Mailing Address: [___] Home [___] Business

Phone Contact: [___] Home [___] Business
___________________________________________________________________
7. Date of Birth:

____|____|____
MO / DAY / YR

___________________________________________________________________
8. EDUCATIONAL RECORD
[Do not use initials for name of institution or for location.]

TECHNICAL INSTITUTE [Less than 4-year course after High School]

Name of Institution _____________________________________
Location _____________________________________________
Specific Course _______________________________________
Date:From-To ____________ | ___________
Date of Graduation ____ | ____ [Month/Year]
Degree Granted or Hours Earned________________________________

COLLEGE OR UNIVERSITY

Name of Institution _____________________________________
Location _____________________________________
Specific Course _____________________________________
Date:From-To ____________|___________
Date of Graduation ____|____
Month/Year
Degree Granted or Hours Earned________________________________

GRADUATE STUDY
Name of Institution _____________________________________
Location _____________________________________
Specific Course _____________________________________
Date:From-To ____________|___________
Date of Graduation ____|____
Month/Year
Degree Granted or Hours Earned________________________________

OTHER
Name of Institution ___________________________________________
Location ___________________________________________________
Specific Course _____________________________________________
Date:From-To ____________|___________
Date of Graduation:
____ | ____
Month / Year
Degree Granted or Hours Earned________________________________

___________________________________________________________________
9. PROFESSIONAL REGISTRATION [Do not include E.I.T.]
Note: Professional Registration is not a requirement for ASHRAE membership.

Principal License Number______________________________________

Principal Location of Registration________________________________

Years Held ___________

Total Number of Licenses______________________________________

___________________________________________________________
Place Engineering Stamp Here

___________________________________________________________

___________________________________________________________________
10. EMPLOYMENT RECORD [List Present Affiliation First]

Use additional sheets if necessary.

Date: From __________ TO __________
Name and Address of Employer___________________________________
[Describe Type of Business]_____________________________________
Your Title:____________________________________________________

Duties:[Describe your duties; State clearly duration of
Responsibility]
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Date: From __________ TO __________
Name and Address of Employer__________________________________
[Describe Type of Business]___________________________________
Your Title:___________________________________________________

Date: From __________ TO __________
Name and Address of Employer___________________________________
[Describe Type of Business]______________________________________
Your Title:_____________________________________________________

Date: From __________ TO __________
Name and Address of Employer__________________________________
[Describe Type of Business]___________________________________
Your Title:___________________________________________________

___________________________________________________________________
11. Mailing labels-Mailing labels of ASHRAE members may be made available to
educational institutions or other groups for non-commercial use.

If you DO NOT wish to receive these mailings, please check here. [___]

______________________________________________________________
12. HANDBOOK- The annual ASHRAE handbook is available in two versions.
Please check the version that you prefer to receive.

[___] IP [Inch Pound] [___] SI [Metric]

___________________________________________________________________
13. The following information is required to determine your current activities and areas
of technical interest. Please enter the appropriate codes in the blocks provided. REFER
TO CURRENT ACTIVITIES OF TECHNICAL INTEREST LIST FOR APPROPRIATE CODES.

CURRENT ACTIVITIES
1. PRINCIPAL ACTIVITY OF YOUR FIRM/ORGANIZATION ____|____

Other [Specify]_______________________________________

2. TITLE WITHIN YOUR FIRM/ORGANIZATION _____________
3. FUNCTIONAL ACTIVITY IN FIRM/ORGANIZATION _____________
4. SIZE OF FIRM/ORGANIZATION _____________

BROAD AREAS OF HVAC&R INTERESTS [Use codes on attachment to indicate your first, second and third choices.]

First _______
Second ____
Third ______

TECHNICAL COMMITTEE-RELATED AREAS OF INTEREST [Use codes on
attachment to indicate your first, second and third choices.]

First _______
Second ____
Third ______
___________________________________________________________________
14. CERTIFICATION BY APPLICANT

The undersigned certifies that all statements are correct and agrees to accept the
grade which is voted by the ASHRAE Board of Directors.

Signature:_____________________________ Date__________________

___________________________________________________________________
15. REFERENCE [ASHRAE membership is not required to be a qualified reference]

I know the applicant by_____________________ association [personal/business]
for approximately ________years. To the best of my knowledge, the above information
is correct and, as such, I recommend the applicant be elected to membership.

Additional Comments: _________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Signature:____________________________________ Date__________

Reference Name [Please Print]_________________________________

Form Revised 1/23/99