Philippine Corrosion Society

Membership Application Form

New

Type of application:

Renewal

Change

PERSONAL AND COMPANY DATA

Home
Office

Please complete both your home and office addresses. Where do you want information mailed?
NAME

COMPANY

BUSINESS ADDRESS

ZIP/POST CODE

COUNTRY/PROVINCE

BUSINESS TELEPHONE NUMBERS

E-MAIL ADDRESS

HOME TELEPHONE NUMBER

FAX NUMBER

MEMBERSHIP PROFILE DATA

Information about your technical and professional interest is maintained in the PhiCS database to serve you better. This data will be used to
send special notice of information relevant to you. Please tell us about yourself by checking appropriate information.
A. Sex:

Male
Female

G. From the list below, choose the classification that best describes your companys
function (choose one only):

Power Plant/Electric Utility

Research Services
Refining
Aerospace

B. Education Level:

High School Diploma

Associates
Bachelors

Bridges & Highways

Municipal Water Distribution/Treatment
Industrial Water Treatment
Other

__________________________

Masters
Doctoral
Post-Doctoral
Other, please describe:

Metals/Mining
Plastics/Non-Metals
Pulp & Paper
Railcar/Tank Trucks
Construction
Coating & Lining Application
Testing Services
Oil & Gas Pipelines/Storage Tanks
Original Equipment Manufacturer
Engineering/Architecture/Consulting Firms
Measuring/Analyzing & Controlling Instrumentation
Chemical Processing/Process Industries & Allied Products
Coating & Lining Manufacturer/Distributor
Ships/Marine Structures/Offshore Platforms

C. Have you earned a Professional Engineers license?

Yes

No

D. With regard to corrosion product/services,

I consider myself primarily a:

User/Consumer
Supplier/Producer
Both

H. Birthdate

E. My professional interests are:

Cathodic/Anodic Protection
Chemical Process
Coatings and Linings
Inhibitors
Materials Selection Metals
Materials Selection Non-Metals
Design
Testing & Monitoring
Other ________________________

I hereby certify that the above information are true and correct:

_________________________________________________
Signature over Printed Name

_________________________
Date

E. My principal job function is (choose only one):

Management
Sales/Marketing
Engineer
Scientist/Researcher
Technical/Technologist
Professor/Teacher

Contractor
Inspector/QA/QC
Chemist
Designer/Architect
Maintenance
Purchasing

Attach 2x2 photo