Application Form for Wiley Sponsored Membership

Please copy and paste the form below into the text of your email message, complete and email this form to Bob Cavana, Chair of the Complimentary Society Memberships Committee. In the subject line of your email message, please write: APPLICATION FOR WILEY SPONSORED MEMBERSHIP TO SDS. Email address: Bob.Cavana@vuw.ac.nz

Name:

Present Appointment:

Email address for correspondence:

Do you qualify for normal subsidised Society membership (i.e. your salary is less than the equivalent of US$20,000 per year)? Indicate yes or no.

What is your country of residence/work?

Does this country qualify as a 'low income' or developing country as defined by the scheme - annual average GDP per capita is less than US$15,000? Indicate yes or no.

Personal Statement: Limit to 300 words or less.

Referee's Name:

Is your referee a System Dynamics Society member? Indicate yes or no.

Referee's Position/Organisation:

Referee's Email Contact Address:

Referee's Statement by referee to support application: Limit to 100 words or less.

I have read and agree to accept the conditions of the scheme and decision of the committee. All details supplied are accurate to the best of my knowledge.

Signed: (Type in your name as an electronic signature.)
Date:



RLS October 4, 2005