FUN Information Form 2007 / Faculty for Undergraduate Neuroscience

Welcome to the FUN Information Form
for Individual Members !

| Go to Membership Form for ORGANIZATIONS |

Please help us update and maintain accurate membership records! If your listing in the Membership Directory needs revision, please submit the correct information on this form. Thank you!

FUN INDIVIDUAL MEMBER - INFORMATION FORM
(Form revised 3-16-2008)

Directions: Please complete the form and click the "Submit Information" button at the bottom of the page. Use the "Tab" key to move between information fields. All fields marked with a red *are required.

Does this submission contain * NEW information REVISED information

Prefix:

* First Name (or Initial):

Middle Intial (or Name):

* Last Name:

* Position:

If Other:

* Institution / Company Name:

Department:

* Street Address:

* City:

* State / Province:

Province / Other:

* Zip / Postal Code:

* Country:

If Other:

* Email Address (primary):

Email Address (secondary):

Phone Number:

Area code: ( ) ext.

Secondary Phone Number:

Area code: ( ) ext.

Personal Webpage URL:

http://

Institutional/Department Webpage URL:

http://

Primary Area of Specialization:

Secondary Area of Specialization:

* Are you currently a FUN Member?

Yes No Not Sure I'm Joining Now

Approximate Year Joined?

* Do you wish to join the FUN E-Mail list? Yes No
Please note: Nearly all FUN communications are transmitted by e-mail .

* May we publish your contact information in the FUN website directory? Yes No
PRIVACY STATEMENT

Any Comments?

Remember! Fields marked by * are required.

Please note: Submitting the form will not automatically update the information in the on-line directory! Please do not submit more than one form unless you are submitting a corrected form. Contact the FUN webmaster with questions regarding this form or the website directory.

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PRIVACY STATEMENT: All information included in the membership directory is intended for use by FUN members only (all categories). No commercial use of this directory is allowed without express prior permission. For questions regarding the use of the membership database please contact the FUN President .