Fusion Membership Application Form

Fusion - The Open University Physics Society

Fusion Membership Application Form
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Please fill in with block capitals!

(Download Fusion Flyer promotional leaflet)


Title	Surname	Forenames

Gender†	Date of Birth†	Academic Institution

Address

Town/City	County	Post Code

Telephone (day)†	Telephone (evening)†	OU Region Number & P.I. No

Email Address (please print clearly in block capitals)		Date started with OU

Current OU course code(s)	Leading to (named degree, BSc or BA)	Expected completion date†

Previous OU course code(s)	Please indicate details to be included in the contact list which is available to all members:	___ Tel (Daytime) ___ Tel (Evening) ___ Past Courses ___ Current Courses ___ Email ___ None

*I wish to join Fusion - The Open University Physics & Astronomy Society as a Student/Associate Member** for ___ 1 year @ £7.00 ___ 3 years @ £18.00 ___ 5 years @ £25.00		£

If accepted for Fusion membership I also wish wish my details to be forwarded to the Institute of Physics (IoP) for election as a Student Member. I agree to abide by the Institute's Charter and Bylaws. I am studying a course containing physics. (Note that Student Membership of the IoP can only be renewed directly with the IoP.)

Please send me the following Fusion T-Shirts at the special new-members' price of £7.50‡ each, and/or Fusion Sweatshirts at £11.00‡ each. (Write in quantity for each size/design.) T-shirt colours may vary; email t-shirts@oufusion.org.uk for details of sizes and colours currently available (view current designs).

Design	Size	S	M	L	XL	XXL	£

Maxwell							£

Schrödinger							£

Einstein							£

Sweatshirt							£

I enclose a cheque/postal order (payable to Fusion) for the total amount of							£

Data Protection I further agree that the personal details given on this form may be held on computer systems which will be used only for the administration of the Open University Physics & Astronomy Society and the Institute of Physics.		I agree/disagree* that my name and address be made available to suppliers or service providers outside the Open University Physics & Astronomy Society or the Institute of Physics.			I agree/disagree* that my name and email address be included on PEERS, an Institute of Physics service providing a moderated, searchable global email directory of people working in science.

Signed					Date

Please tell us how you heard about Fusion: tick option and specify course number etc ___ Course Mailing ( ) ___ Course Website ( ) ___ Sesame ___ Summer School ( ) ___ Science Revision Weekend ___ Maths Revision Weekend ___ Other - please specify ( )

Note: Prices and membership fees on this Application Form are expected to be valid until January, 2010, but are subject to change without notice. Email for current pricing. Please note: Fusion is run entirely by volunteers in their spare time. Membership processing may have to compete with day jobs, families and course work. Please be patient. Key: †optional if only joining Fusion, *delete as required, ‡includes packing and UK postage only.

Please send your completed Application Form and fees to: Fusion Membership, 10 Durham Gardens, Waterlooville, Hampshire, PO7 7BB