DRG Membership Form

Detroit Rubber Group Membership Form
Revised April 8, 2022
Step one: Please indicate membership type:
_________ Individual at $25/year
_________ Corporate at $200/year (allows for up to 15 people for one fee)
Step two: Please indicate payment type:
_______ Check, made payable to Detroit Rubber Group, Inc.
_______ Credit card, please fill in details below
CC number________________________________________________________
Billing zip code_____________________________________________________
Expiration date (MM/YY) _____________________________________________
Security code ______________________________________________________
Step three: Please provide your contact information:
Name ____________________________________________________________
Company__________________________________________________________
Title: _____________________________________________________________
Email:____________________________________________________________
Address:__________________________________________________________
_________________________________________________________________
Phone:___________________________________________________________
Member of Rubber Division, ACS? (YES/NO)______________________________
Member of American Chemical Society? (YES/NO)_________________________

Step four: For those choosing the corporate membership, add up to 15 contacts below:
Name Title Email
Member
of Rubber
Division,
ACS?
(Y/N)
Member of
American
Chemical
Society?
(Y/N)
1
2
3
4
5
6
7
8
9
10

11
12
13
14
15
Kindly return by mail or email as follows:
Detroit Rubber Group, Inc.
P.O. Box 113
Ortonville, MI 48462
detrubbergroup@gmail.com
(Kindly put the word “Membership” in the subject line of the email)