Nomination For Sigma Xi Membership

Please fill out the following form as completely as possible, thanks!

Please enter your name as you would like it to appear on your Sigma Xi certificate.

First Name Middle Name Last Name

Preferred Prefix:

Major Department              Institution
Campus Address   Phone FAX

Home Street Address City State
                            Zip                           Country
                      Email 1             Email 2

Which address should be used for Sigma Xi mailing? Which email address?

Are you a Student?
If Yes, what is your year of graduation? Expected Degree?
If No,  what is your highest degree?       Year Obtained?

Major Research Field Other?
Education (Include Institutions, Dates, and Degrees Obtained)

Professional Career (Three most recent positions: include Institutions, Dates, and Position Titles)

For Associate (Student) Membership, please enter a brief statement of your research
or independent work.

For Full Membership, list the nominee's most recent, first-authored, refereed publications (a
minimum of two papers required, Ph.D. thesis is acceptable) or patents. You may attach a list
of publications, patents or similar supporting evidence.

Sigma Xi Fees:

Will you attend the spring banquet:

Banquet Fees:

Meal card number:

Please make checks payable to Claremont Colleges Chapter of Sigma Xi, and
send via campus mail to Patricia Sparks, Physics Department, Harvey Mudd College.

THANKS!!!