IRANIAN-AMERICAN PHYSICISTS NETWORK GROUP
Iranian-American Physicists (IrAP) Network Group consists of members of the American Physical Society (APS) with common interest in Iranian culture who believe in the power of dialog to bridge between American and Iranian people, and who recognize that science is a tool for expanding democracy. Due of $40 ($20 student) is payable no later than the end of annual APS March meeting to the treasurer of the IrAP Network Group.
AFFIRMATION AND LIABILITY RELEASE
I understand and agree that neither IrAP Network Group, nor its Directors and individual members may be held liable in any way for an occurrence in connection with membership activities, which may result in injury, death, material, financial, or other damages to any of myself, family, heirs or assigns. In consideration of permission to participate in such activities, I hereby personally assume all risks in connection with these activities, for any harm, injury, or damage which may befall me while participating in any events with the IrAP Network Group or any of its Directors and individual members, including all risks connected therewith, whether foreseen or unforeseen, and also including transit to and from the site of any event. I further agree to save and hold harmless, forever, IrAP Network Group and its members from any claim by anyone of myself, my family, estates, heir or assigns, arising from participating in such Network sponsored events and activities.
I further state that I am of lawful age and legally competent to sign this Affirmation of Release, that I understand the terms herein are contractual and not mere recital, and that I have willfully signed this document of my own free act.
I, the undersigned individual, declare that I have read the Iranian-American Physicists Network Group Bylaws thoroughly and I have understood the terms within and their implications. Hereby, by signing this Membership Application form, I accept to abide by the rules of the Iranian-American Physicists Network Group and I will act in harmony with the laws of the United States of America, the regulations of the American Physical Society, and the rules of the Iranian-American Physicists Network Group (as enunciated in its Bylaws).
SIGNED: _________________________________DATE: ________________________________
PRINT NAME: ____________________________________
WORK PHONE: __________________________________________________
HOME PHONE: __________________________________________________
OFFICE USE ONLY
AMOUNT RECEIVED: __________________
PAYPAL TRANSACTION #: ___________________
DIRECTOR SIGNATURE: _______________
Please email this page with your membership dues (you can use paypal to pay your membership fee) to:
Farbod Shafiei, Ph.D.
Department of Physics
University of Texas at Austin
2511 Speedway RLM 5.208
Austin TX 78712