SHAC Online Membership Application Form

Please fill in all the fields in this form.

NB
If any of the fields does not apply to you, please insert a dash: -
If any of the fields are left blank the application will not be submitted.

If you have any questions regarding this application form, please contact:

SHAC Honorary Treasurer
John Perkins
19 Nethercote Road,
Tackley,
Oxfordshire, OX5 3AW.
E-mail: shacperkins@googlemail.com

Name	Title Dr Mr Mrs Ms Miss Surname Forename(s)
Address	County/State Postcode/Zip Country
Email
Institutional Affiliation (if appropriate)
Areas of interest in the history of alchemy and chemistry
Full-time Postgraduate Students	Yes No Institution Supervisor (Please ask your supervisor to confirm your student status)
Subscription Click here for details	Full for 2008 Full for 2008 and 2009 Student for 2008 Student for 2008 and 2009
Payment Method	PayPal Cheque Postal Order Standing Order Direct Giro Transfer
We are intending to set up an email distribution list to keep members informed of the Society’s activities. Please indicate whether you wish to receive email communications for the Society Yes No Data Protection Act 1998: Please note that the information you supply on this form will be kept on file in electronic form. It will be made available only to SHAC officers and will be used solely for the administration of the Society.

Last updated 28 April, 2008