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                                                                                                      Application for:
MEMBERSHIP APPLICATION                                                                                   Regular Member
                                                                                                         Associate Member
                                                                                                                                       $60.00
                                                                                                                                       $60.00
SOCIETY OF BROADCAST ENGINEERS                                                                           Student Member                $18.00
9247 North Meridian Street, Suite 305                                                                    Reinstatement                 $60.00
                                                                                                         (former Member #____________)
Indianapolis, IN 46260
                                                                                                         Change in grade to Member $60.00
Phone: (317) 846-9000 Fax: (317) 846-9120
                                                                                                         (for student/youth members only)
(Please type or print)

Payment Method:          Check     Money Order (payable to SBE)      American Express      MasterCard       Visa   Total: $__________
Credit Card #___________________________________________________________________ Expiration Date_____________________________
                            (American Express, MasterCard or Visa ONLY)
                         Information provided in this application will be used to determine membership eligibility.

____________________________________________________________________________                      (________) ______________________
Last Name                               First                           MI                        Home Phone

____________________________________________________________________________                      (________) ______________________
Mailing Address                                                                                   Business Phone

____________________________________________________________________________                      (________) ______________________
City                                       State           Zip Code                               Fax Number

The above mailing address is:              Home                 Business

____________________________________________________________________________                      ________________________________
Place of Employment                                     Date Employed                             Date of Birth (MM/DD/YY) optional

_______________________________                  ________________________________                 _____________________________
Current Job Title                                Type of Facility                                 E-mail Address

_____________________________________________________________________________________________________
Description of Duties




Total years of responsible Engineering experience: _________                          Radio      TV      Other (check all that apply)

If accepted, please enroll me in Local Chapter #_______ Location: ____________________________________

SBE Certification # __________________ (if applicable)

Sponsor's Name/Who introduced you to SBE? (optional): _______________________________________________

                                                      EXPERIENCE RECORD
List in chronological order, beginning with the most recent, all formal experience in Broadcast Engineering or related
employment. Indicate field(s) of specialization under "Position." Please do not limit yourself to the spaces below.
 From          To                                                                                                         Type of
Mo Yr         Mo Yr                  Company Name and Location                             Position or Title              Facility




                                     ADDITIONAL INFORMATION REQUESTED ON REVERSE SIDE

                                                MEMBERSHIP COMMITTEE ACTION
  Approve        Disapprove                                                                                 Grade:_____________________
Comment:_____________________________________________                                                       Records: ___________________
Signature: _____________________________________________                                                    Appl Notified: ______________
                                                                EDUCATION
 From          To                      College, University                       Credits or
Mo Yr        Mo Yr                    or Technical Institute                     Yrs Compl              Course or Major                 Degree




   * If applying for student member status, you must complete the following:

   Program/major currently enrolled in: _____________________________________________________________

   You are a (check one):                 Full-time Student                Part-time Student

   To verify your student status, have your faculty advisor sign below or send a photocopy of your
   student identification card along with this application and dues payment. Application will not be
   considered without one of these forms of identification.

    _______________________________________________________                                   __________________________________
   Signature of faculty advisor, dean, department chair, etc.                                  Title


                                                                REFERENCES
                                          List two references who are familiar with your work.
         Name                         Company Name and Location                                 Position or Title                   Phone




                                 OTHER PROFESSIONAL LICENSES OR CERTIFICATES




                                                      SPECIAL ACHIEVEMENTS
 List awards, patents, books, articles, short courses, seminars related to broadcast-communications technology, etc.




Have you ever been convicted of a felony?                            Yes           No      If yes, describe in full. (Use additional
paper if necessary.)
_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

If approved, I agree to abide by the Society of Broadcast Engineers By-Laws and Canons of Ethics.

____________________________                        _________________________________________________________________
Date                                                Signature

       SBE dues are not deductible as a charitable contribution for federal income tax purposes, but may be deductible as a business expense.
                 SBE estimates that 2% of your dues are not deductible because of SBE's lobbying activities on behalf of its members.