Information for non-IEEE Members on Affiliating With the IEEE Society on Social Implications of Technology

To become an affiliate of SSIT, supply all information requested below, and send with payment to the indicated address.

All affiliates of SSIT receive IEEE Technology and Society Magazine at no extra charge.

[ ] I am not a member of IEEE, but would like to become an affiliate of IEEE-SSIT ($58 IEEE + $24 SSIT = $82 Total).

Please supply the following information

Name:
Title:
Company or University:
Address:
City:
State:
Zip:
Phone:
Fax:

Signature:
Date:

Date of Birth:

[ ] Male [ ] Female

Were you ever a member of IEEE?
If yes, please supply:
Membership Number:
Grade:
Year expired:

Education (highest level completed):
Institution:
Degree received:
Date:

Complete item a) *OR* item b):

a) Professional Society(ies) - one or more - in which membership is currently held and admission year.
Society Name/year:
Society Name/year:
Society Name/year:

OR

b) Signatures of three IEEE Members (not Affiliates) who are sponsoring your application.
Signature/IEEE No.:
Signature/IEEE No.:
Signature/IEEE No.:

Enclose $82 and send to:
IEEE Service Center
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445 Hoes Lane
Piscataway, NJ 08855