Honolulu Chapter Member Nomination

Title

Dr.

Other…

* Candidate’s First name

* Candidate’s Last Name

Preferred name / nickname:

* Occupation:

* Street Address or P.O. Box:

* City, State ZIP

Mobile phone:

Other phone:

* Email:

Spouse’s name (optional):

* Profesional and/or civic activities:

Applicable skills or abilities:

* Preferred membership level (note: membership is for the ARCS fiscal year, July 1–June 30)

$300 Annual Member

$2,500 Sustaining Member (One-time payment covers 10 year-membership)

$50 Young Professional (Within 5 years of completion of PhD or post-doctoral assignment)

To be decided later

Referred by (optional)