Membership and Journal Subscription Form:

Membership for 2012

Also available as a PDF or Word Document

Section 1: Contact Details (Please write legibly. All details will remain confidential.)

Title: Initials:
Surname:
Address:

Tel: Fax:
E-mail address (required):


Section 2: Current Fees (Please circle one box)

Type of membership Membership Only* Membership + subscription to the PAPER J. Mol. Graph. & Mod. (8 issues) Subscription to 8 issues of the PAPER J. Mol. Graph. & Mod. for existing members#
Full Membership £ 30 £ 72 £ 42
Retired/Career Break/Unemployed £ 15 £ 45 £ 30
Student Membership £ 15 £ 45 £ 30

* Subsidised subscription to the electronic J. Mol. Graph. & Mod. is available to members on request.
# Does not refer to members from previous years, only those who have registered as non-members for MGMS meetings held in 2012 or attended the YMF2011 as students.


Section 3: Payment


Total Amount Paid (Membership + Subscriptions):


Payment Methods (tick box that applies)
By Standing Order / Internet Banking
The membership secretary will email you with the MGMS bank account details on receipt of your completed form
By Cheque
Please make cheques payable to the Molecular Graphics & Modelling Society
By Card:
Please circle card type: Switch/Delta/Visa/Mastercard
We do not accept American Express


Card Details (DO NOT SEND CARD DETAILS ELECTRONICALLY)
Card Number:

(16 digits for Visa/Delta/Mastercard, 18 for Switch)
Security code:

(Last 3 digits on signature bar)		 Expiry date:

 Issue number:

(Switch only)
Card billing address:
If receipt required, tick box: please return by [] email or []in stamped addressed envelope (which I enclose)


Section 4: Signatures

Signature: Date:

For student membership, a supervisor's signature is also required: I hereby declare that the above is a student.

Supervisor's
name:		 Signature:

Send to: Dr Jamie Platts, School of Chemistry, Cardiff University, Park Place, Cardiff, CF10 3AT, UK.