International Society of Iraqi Scientists
Membership Application Form

Important
1. Please print this application form and fill in the required fields; use separate extra sheet(s) if required.
2. Fax or mail the completed application form with a copy of your resume.

Full Name [First Middle Last]: -----------------------------------------------------------------------------------------
Date of Birth [mm/dd/yyyy] (Optional): -----------------------------------Sex (Optional):-----------------

Telephone: ----------------------------------------------------Fax: ---------------------------------------------------------
E-mail: ----------------------------------------------------------------------------------------------------------------------------

Postal Address:
House No. & Street Name: ------------------------------------------------------------------------------------------------

City: --------------------------------------------------------------------------------------------------------------------------------

State (Province): ---------------------------------------------------------------------------------------------------------------

Zip Code (Postal Code): -----------------------------------------------------------------------------------------------------

Country: ---------------------------------------------------------------------------------------------------------------------------

Academic Degree Awarding Authority Year Awarded Specialization
       
       
       
       

ISS WHo's Who Directory:
Do you want your particulars to appear in the ISS Who's Who Directory to be published in the future?

YES NO

PLEASE READ BEFORE SUBMITTING
1. Membership applications are thoroughly studied by a scientific membership committee and when found eligible for membership, the committee then recommends to the ISS Board of Directors the grade of membership for approval.
2. Applicants will be informed by the decision of the Board of Directors in due time and date.
3. The ISS Board of Directors preserves the rights to terminate membership of any member if found that member has submitted false information to gain the membership or its grade.
4. As a member of the ISS you agree to accept and abide by its bylaws and regulations.

Signature of applicant-----------------------------------------                      Date------------------------

International Society of Iraqi Scientists, P.O. Box 4445, Dearborn, Michigan 48126, United States of America
Fax  (248) 538 - 6034