BRAIN BEE INTERNATIONAL



Vermont Chapter of the Society for Neuroscience

2017 Annual Membership Payment Form

Your membership dues are vital for our Chapter to support community outreach activities such as the Vermont Brain Bee and Brain Awareness Week, as well as to provide travel grants for our students to attend the Annual Meeting of the Society for Neuroscience.

Please submit the following VT SfN Membership Payment Form to Victor May, UVM Department of Neurological Sciences, HSRF 428, 149 Beaumont Ave., Burlington, VT 05405

Please list all members you are paying for:

|Name(s) |Email Address |Institution/Affiliation |Position |Membership Dues $ Amount |

| | | | |(Faculty - $45, Staff and |

| | | | |Post-docs - $35, Grad Students |

| | | | |- $20, Undergrad/High School |

| | | | |Students – Free) |

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|Total Amount: | | | | |

I am paying by:

[pic] Check (Please make checks out to the Vermont Chapter, Society of Neuroscience, which is a registered non-profit organization).

[pic] Credit Card (Please complete the payment information below)

|Name on Card: | |

|Visa/MC/AMEX: | |

|Credit Card Number: | |

|Expiration Date: | |

|3 – 4 digit CVV (Card Verification Value) number: | |

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|Billing Zip Code: | |

*This form will be shredded once the payment has been processed. You will receive a receipt after your payment has been received.

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