Return To:

1100 Johnson Ferry Road

Suite 300
Atlanta, GA 30342
Phone: (800) 950-7354
FAX:
404-252-0774
Email: info@smrp.org
Web: www.smrp.org

INDIVIDUAL MEMBERSHIP
APPLICATION

Contact Information
Name:
________________________________________
Credentials (e.g.
PE):_____________________________
Company:
_____________________________________
Title:
_________________________________________
Address:
______________________________________
Address:
______________________________________
City, State Zip:
_________________________________
Country:
______________________________________
Foundation Contribution of

_________* (Optional)

Select Chapters/SIGs (additional dues may apply)

California: $25
Carolinas: $0
Central Ohio: $24 Chicagoland: $0
Detroit-Windsor: $25 East Tennessee: $25
Hamilton, ON: $0 Houston: $0
Indiana: $25
Middle TN: $0
Mid-Ohio Valley: $0
Nebraska-Iowa: $0
NE Florida: $0
North Texas: $0
Northern Ohio: $25 Pacific NW $25
SE Virginia: $0
Pharma and Biotech SIG: $15
Georgia: $25
Oil, Gas,
Petrochemical SIG: $15
Reliability Analytics SIG:
$15

Select Membership Level

$155 One-Year Membership
$310 Three-Year Membership
$25 Emerging Professional (Student)

PAYMENT INFORMATION
Total Amount Paid __________________________
address below.

Please mail all check payments to the

Payment Method (CIRCLE ONE)

Make all checks payable to:

VS

DC

MC

AX

PO#_______

Society for Maintenance and Reliability Professionals

Credit Card #: _______________________________

P.O. Box 116680

Exp. Date: ________ Total Amount: _________________

Atlanta, GA 30368 - 6680

Name on Card: ______________________________

Signature: __________________________________
SMRP membership dues are not deductable as a charitable contribution, but may be deductible as an ordinary and necessary business expense. Please
consult your tax advisor for more information. Foundation contributions are tax deductable as a charitable contribution.

Getting to Know You

Thank you for joining SMRP in order to better serve you, SMRP strives to keep accurate
records about our overall membership demographics and about you in particular.
Answering the following questions will help us to better customize our services and
responses to your requests and needs.
Please indicate (one) the industry you are working most
closely with.

Manufacturing Industries:
Apparel (and other finished products made from
fabrics)
Chemicals/ oils/ energy
Computer equipment
Electronics/ instruments
Fabricated metal products
Food & kindred products
Furniture & fixtures
Industrial & commercial machinery
Leather & leather products
Lumber& wood products
Machinery/ electrical
Measuring, analyzing & controlling instruments
Pharmaceuticals
Primary metals
Printing, publishing & allied industries
Pulp & paper
Rubber & miscellaneous plastic products
Stone, clay, glass & concrete
Textile mill products
Tobacco products
Transportation
Other _________________________________
Non-Manufacturing Industries:
Commercial facilities
Hospitals
Mining
Utilities
Other _________________________________
Government/ Academic/ Military/ Consulting:
College or University
Consulting
Government Agency
Military (specify branch)
Research
Other _________________________________

What is your role in your organization?

Craftsperson/Technician
M&R Engineer Professional
Other Engineering Professional
Management
Consultant
Educator/Trainer
Other_________________________________

What is your gender?

Male

Female

What is your birthdate?

____________________________
How many years have you been in maintenance and reliability?

Less than 5
6-10
11-15
16-20
More than 20

Why did you join SMRP?

Annual conference
Benchmarking
Case studies
Chapter
meetings
Executive member meetings
Networking
Publications
Speakers
bureau
If you were referred by a colleague, who referred you?

__________________________________________
____