SOUTHEASTERN Regional Genetics Group™, Inc (SERGG)

STUDENT MEMBERSHIP

ANNUAL MEMBERSHIP DUES

Professionals - $25 - please go to the Professional Membership Form (no verification required)

Students/Trainees - $10 (verification required).

SERGG, Inc. accepts payment by check (made payable to “SERGG, Inc. ”) or by credit card (Visa, MasterCard, Discover, American Express) via PayPal.

Please fill in the following information:

* Required in order to process your application

*First Name:		Middle Initial:
*Last Name:
*Curent Position Title:
Degree(s):
*Address Line 1:
Address Line 2:
Address Line 3:
*City:
*State:		*Zip:
*Country:
*Phone:	[format: 555-555-1234]	Fax:
*E-mail address:
*Confirm E-mail address:
*Level of Membership: Students/Trainee - $10 A letter from your faculty supervisor is required. It can be either faxed, emailed, mailed or uploaded by clicking on the Browse button below. Instead of uploading the file, I will use the following method: Fax to (404) 778-8562 Email to mlane@sergginc.org Mail to SERGG, Inc.™ P.O. Box 1642 Decatur, GA 30031-1642

For further information, please contact us