PIRA Membership Form

Date:____________________________

____ I wish to become a new member of the PHYSICS INSTRUCTIONAL RESOURCE ASSOCIATION (PIRA).

____ I am renewing my membership.

Enclosed is $10.00 (US funds) which is to cover my membership fee which includes one year's subscription to the PIRA Newsletter with both print and on-line access.

Name: Mr., Mrs., Miss, Dr., Prof. (print):

____________________________________________________________

School Affiliation: _____________________________________________

Department: __________________________________________________

Address1: ____________________________________________________

Address2: ____________________________________________________

City: _____________________ State: ____ Zip + 4___________________

Phone: ______________________________________________________

E-mail address: _______________________________________________

Home page: http://_____________________________________________

Title: _______________________________________________________

I learned of PIRA through _______________________________________

Specific areas of interest: ________________________________________

____ Check here if you wish to participate in PIRA Activities.

____ Check here if you would like your information available on the password protected PIRA website. This would include name, work phone, institution and email address.

Make all remittance payable to: PIRA Mail with fees to:
PIRA C/O David Sturm
274 French St
Bangor ME 04401