INTERNATIONAL COUNCIL ON SYSTEMS ENGINEERING
2150 N 107th St #205
Seattle,WA 98133-9009 (USA)
Phone: (206) 361-6607 or (800) 366-1164
Fax: (206) 367-8777
Email: incose@halcyon.com
Internet Site: http://www.incose.org/

Individual Membership Application

FOR NEW MEMBERSHIPS

1. Membership Type

Please circle the amount remitted:

Month of Joining *	Jun Jul Aug	Sep Oct Nov	Dec Jan Feb	Mar Apr May
Regular Membership **	80$	60$	40$	100$
Student Membership ***	10$	10$	5$	10$

* Membership year is from June 1 to May 31.
** Dues are 80$/yr beginning in Jun 99.
*** Student members must be enrolled at least 3/4 time in engineering or related fields.

2. Personal Information

OPTIONAL-- Attach a business card and provide additional information below.

Name: FIRST______________

M.I. ____

LAST______________

Nickname ______________

Check One: Mr. CheckBox

Ms.

Dr.

Mailing Address (NOTE - We prefer to mail to your home address):
CheckOne: Home CheckBox

Office

City___________________________	State/Prov__________________________
Zip/PC________________________	Country____________________________
Office Phone____________________	Office Fax__________________________
Email__________________________	Home Phone (Optional)___________________

3. Professional Information

Company / Agency / Institution________________________

Position / Title__________________________

4. INCOSE Chapter Affiliation

Please circle one of the chapters listed in the left 3 columns:

CANADA
Vancouver

GERMANY
German Chapter

HOLLAND
The Netherlands

NORWAY
NORSEC

U.K.
United Kingdom

U.S.A.
Alabama
   Huntsville
   (Huntsville) Arizona
   Central Arizona (Phoenix)
   Southern Arizona (Tucson)
California
   Inland Empire
   (San Bernardino)
   Los Angeles
   (LA, Orange &
    Ventura
   Counties)
   San Diego
   (San Diego)
   SF Bay Area
   (Silicon Valley)

Colorado
   Colorado Front Range
   (Denver)
Connecticut
   Constitution
   (Hartford)
Florida
   Central Florida
   (Tampa Bay)
   Space Coast
   (Melbourne)
Idaho
   Snake River
   (Idaho Falls)
Iowa
   Heartland
   (Cedar Rapids)
Maryland
   Chesapeake
   (Baltimore)
   S. Maryland
   (Lexington Park)
Massachusetts
   New England
   (Boston)
Michigan
   Detroit/Tri-State
Minnesota
   North Star
   (Twin Cities)

Missouri
   Midwest Gateway
   (St. Louis)
Nevada
   Silver State
   (Las Vegas)
New Jersey
   Liberty
   (Rockaway)
Pennsylvania
   Delaware Valley
   (Philadelphia)
South Carolina
   Central Savannah
   River Area
   (Aiken)
Texas
   North Texas
   (Dallas/Ft.Worth)
   Texas Gulf Coast
   (Houston)
Utah
   Wasatch
   (Salt Lake City)
Virginia
   Central Virginia
   (Fredericksburg)
   Hampton Roads Area
Washington
   Seattle Metro
   Tri-Cities
   (Richland)
Washington, DC
   Washington Metro Area

Emerging
Chapters

Swedish
Israeli
FINSEC

Australia
Affiliate
Systems Engineering
Society of Australia
(SESA)

5. Today's Date _____________

Checkbox Please do not publish my addresses, phone numbers and e-mail in the INCOSE Membership Directory.