Membership and Journal Subscription Form:

Membership for 2017

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 Fee
Full Membership 30
Retired/Career Break/Unemployed 15
Student Membership 15

Subsidised subscription to the electronic J. Mol. Graph. & Mod. is available to members on request.




Section 3: Payment

It is possible to pay by cheque, credit/debit card, internet transfer or by standing order; the MGMS would like to encourage you to set up a standing order payment as this is the preferred method.

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
(Please send card details by recorded delivery or courier. DO NOT send card details by normal mail, email, or fax)
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 Steve Maginn, Chemical Computing Group, St Johns Innovation Centre, Cowley Road, Cambridge, CB4 0WS, UK