Philadelphia – Delaware Valley Chapter

Student Membership Application

Name:

Date:

Home Address:

Home Phone Number: Home Fax Number:

Home Email Address:

Current College/University Name and Address:

Program:

College Email Address:

Professional Data:

Education - Name of Colleges/Technical Schools, Degree(s)/Major & Dates Graduated

Professional & Business Experience:

Professional Credentials:

Please indicate:

Membership status with SFPE National, if any Membership No.

Other Professional Society Memberships

Other Professional Credentials: NICET Level CFPS

Other

SFPE Chapter Sponsor

The undersigned, in making application for membership in the Philadelphia-Delaware Valley Chapter of the Society of Fire Protection Engineers certifies that all statements and answers included herein are true in substance and effect, and are made in good faith.

Signature of Applicant Date

The undersigned certifies that the applicant is currently a student in good standing in a Fire Protection/Science program.

Signature of Academic Advisor Date

Entrance Fee: $10.00 to be included with this application. If this application is not accepted, the fee will be returned. If accepted, regular annual dues of $20.00 will be due again in September, unless the applicant is still considered eligible for student membership.

(Make check payable to: SFPE – Philadelphia-Delaware Valley)

Please return this form and check to: M. G. Top Myers, SFPE Treasurer
961 Pottstown Pike
Chester Springs, PA 19425
800-874-5880, x219 Fax 610-321-1011
tmyers@microtrack.com