[TITLELOGO: Women in Science and Engineering]

Ottawa-Carleton WISE Membership Form

New Member     Renewal     Change of Information

Personal Data

Name:
Address:
Home Telephone:
Business Telephone:
Fax Number:
E-Mail Address: Home Business

Background Data

Current Job Title/ Employer:


Area of Specialization:


Education:


Work Experience and Professional Affiliations:(briefly)


WISE Information
To meet the objectives of WISE we NEED volunteers! Would you be willing to volunteer:

as a speaker for a WISE chapter meeting ........................................................... YES NO
as a speaker at a school...................................................................................... YES NO
for student job shadowing................................................................................... YES NO
as a mentor via e-mail ........................................................................................ YES NO
other areas as needed (e.g. committee member).................................................. YES NO


We would like to publish a membership directory which would be distributed only to our members:

May we include your name in our directory.......................................................... YES NO
Would you like a copy........................................................................................ YES NO

MEMBERSHIP CATEGORY
Regular Member ($25 annual fee)
Student Member ($10 annual fee)

Please send your cheque payable to Ottawa-Carleton WISE Chapter to:
Ottawa-Carleton WISE Chapter
Box 35037 Westgate P.O.
1309 Carling Ave.
Ottawa, ON, K1Z 7L3

This form is confidential and for internal WISE use only