Print this page, fill in the information, and mail to the address below.
Membership Application Date____________ Name: First________________________Middle initial____ Last___________________________________ Mailing Address (summer):_________________________________________________________________City:________________________________________ State:_____ Zip:____________________________ Phone: (____)_______________ STAT ID number ________________________________
E-mail: (Please print carefully)_______________________________________________________________ School:_______________________ District:________________________________ ESC Region:_________
JOB DESCRIPTION: (check all that apply)
Elementary College Supervisor, etc. ( )Grade(s) _________ ( )Science Education ( )All Levels ( )Science Specialist ( )Teacher Education ( )K-6 ( )Other ____________ ( )Other ____________ ( )Other ____________
Please check one: ( ) New Member
OR ( ) Renewing member Registration Fee:
( )Regular and Student $10.00 ( )Life Member $100.00 ( )Institutional $100.00 ( )Corporate $300.00
Make checks payable to: Texas Council of Elementary Science
Send to: Vanessa Westbrook 404 Shep Street Austin, TX 78748
Revised 1/07