First Name:

Middle Initial:

Last Name:

Home Address:  Steet Address:

P.O. Box:

City:

State:

Country:

ZIP:

Home Phone:

Preferred E-Mail:

Graduation Date: Degree:

Major: Institution:

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Graduation Date: Degree:

Major: Institution:

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Graduation Date: Degree:

Major: Institution:

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Graduation Date: Degree:

Major: Institution:

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Employment Information (Optional)

Company Name:

Title you hold in company:

Business Address:

Street Address:

Address line 2 (if needed)

City:

State:

ZIP:

Work Phone:

Work E-Mail:

Number of years with current employer:

Survey Questions (Optional)

Are you interested in attending Social Events in your area sponsored by the PSMES or the Penn State Department of Mechanical and Nuclear Engineering?
Yes No

Would you be interested in attending social events at University Park, PA sponsored by the PSMES or the Penn State Department of Mechanical and Nuclear Engineering?
Yes No

Would you participate in annual meetings of the PSMES either in person or by teleconference?
Yes No

Would you be interested in actively participating on any committees of the PSMES responsible for organizing social events or other activities either in your area or at University Park?
Yes No

Are you interested in being a member of the PSMES Board of Directors?
Yes No

Do you want to be contacted by the PSMES regarding your participation a) as a member of the Board of Directors or b) on one or more of the society’s committees?
Yes No

Are you currently receiving the Department Newsletter?
Yes No

Would you be interested in receiving electronic department updates and news via e-mail?
Yes No

Additional Comments: