SNEB Institutional Membership ApplicationDate: ______

Name of Contact Person for Institutional Group– if this person is joining please also complete Member section below:

First:______Last:______

Title:______Email:______

Organization/Company Name______

Mailing Address:______

City______State______Zip______Phone______

Method of PaymentCheck |Mastercard |  Visa |  AmEx
Number of Members ______5______x $200 = _$1000_Dues Amount
+ Additional divisions ______x ______

Total Due: ______

Credit card Number: ______Exp. ______CVV Code:______

Signature: ______Billing Zip Code: ______

Mail this membership application and payment to SNEB, 9100 Purdue Road, Suite 200, Indianapolis, IN 46268 or email (credit card payments only) to

______

Member 1:

First______MI_____ Last______Degree/Credential______

Degree and Experience/Related Organization(if degree is not in nutrition field or indicate degree you are obtaining)
______
Email______Phone______

Mailing Address:______

City______State______Zip______

Member 1 Divisions: You are eligible to join two divisions without charge in your first year of membership.* One division is included with membership in subsequent years. Additional divisions are $10 annually.

CommunicationsDigital TechnologyFood and Nutrition Extension Education

Healthy AgingHigher EducationInternational Nutrition Education

Nutrition Education for ChildrenNutrition Education with IndustryPublic Health Nutrition

ResearchSustainable Food SystemsWeight Realities

Member 2:

First______MI_____ Last______Degree/Credential______

Degree and Experience/Related Organization(if degree is not in nutrition field or indicate degree you are obtaining)
______
Email______Phone______

Mailing Address:______

City______State______Zip______

Member 2 Divisions: You are eligible to join two divisions without charge in your first year of membership.* One division is included with membership in subsequent years. Additional divisions are $10 annually.

CommunicationsDigital TechnologyFood and Nutrition Extension Education

Healthy AgingHigher EducationInternational Nutrition Education

Nutrition Education for ChildrenNutrition Education with IndustryPublic Health Nutrition

ResearchSustainable Food SystemsWeight Realities

Member 3:

First______MI_____ Last______Degree/Credential______

Degree and Experience/Related Organization(if degree is not in nutrition field or indicate degree you are obtaining)
______
Email______Phone______

Mailing Address:______

City______State______Zip______

Member 3 Divisions: You are eligible to join two divisions without charge in your first year of membership.* One division is included with membership in subsequent years. Additional divisions are $10 annually.

CommunicationsDigital TechnologyFood and Nutrition Extension Education

Healthy AgingHigher EducationInternational Nutrition Education

Nutrition Education for ChildrenNutrition Education with IndustryPublic Health Nutrition

ResearchSustainable Food SystemsWeight Realities

Member 4:

First______MI_____ Last______Degree/Credential______

Degree and Experience/Related Organization(if degree is not in nutrition field or indicate degree you are obtaining)
______
Email______Phone______

Mailing Address:______

City______State______Zip______

Member 4 Divisions: You are eligible to join two divisions without charge in your first year of membership.* One division is included with membership in subsequent years. Additional divisions are $10 annually.

CommunicationsDigital TechnologyFood and Nutrition Extension Education

Healthy AgingHigher EducationInternational Nutrition Education

Nutrition Education for ChildrenNutrition Education with IndustryPublic Health Nutrition

ResearchSustainable Food SystemsWeight Realities

Member 5:

First______MI_____ Last______Degree/Credential______

Degree and Experience/Related Organization(if degree is not in nutrition field or indicate degree you are obtaining)
______
Email______Phone______

Mailing Address:______

City______State______Zip______

Member 5 Divisions: You are eligible to join two divisions without charge in your first year of membership.* One division is included with membership in subsequent years. Additional divisions are $10 annually.

CommunicationsDigital TechnologyFood and Nutrition Extension Education

Healthy AgingHigher EducationInternational Nutrition Education

Nutrition Education for ChildrenNutrition Education with IndustryPublic Health Nutrition

ResearchSustainable Food SystemsWeight Realities

______