Associated Chemistry Teachers of Texas Membership Application
[Current members should use this form to update information]
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Associated Chemistry Teachers of Texas Membership Application [Current members should use this form to update information] |
Date:
Last Name: First Name: MI:
e-mail address:
alternate e-mail address (in case first e-mail address does not work):
School District: ESC Region:
School Name:
STAT Member [use the mouse to click Yes or No]: Yes No
Home Address [where mail can be sent even during the summer]:
Street: City: State:
Zip Code:
Phone Numbers [please include area codes; example: 915-000-000]:
Home: School: Fax:
reACTant Information [how do you want to receive the newsletter]:
Electronic copy via Internet Hard copy via the mail
Job Description [please use the mouse to check all that apply]:
| Teacher | Supervisor | Two-Year College |
| High School | Principal | University |
Other [please elaborate in the text box provided]:
Dues [use the mouse to check all that apply]:
| $10.00 |
One Year ACT2 |
New | Renew |
| $20.00 |
Two Years ACT2 |
New | Renew |
Total:
| Make one check payable to | For Office Use Only: |
| ACT2 and mail to: | Date Received: |
| Rosendo Garcia | Cash_______Check #______ |
| ACT2 Treasurer | Check Date: |
| 17401 Dashwood Creek Dr. | Acct. Name |
| Pflugerville, TX | New Due Date: |
| 78660 | |
| Press the submit button to mail the form! | |