Name:        

* Employer:

* Address:
  Check one:  Business Home

Check here if you do NOT want your information published in the Membership Directory.

* Telephone:
           voice:        
                        Area Code

           fax:            
                       Area Code

E-mail (important!): 

* National Member:
   If you are not a national member, you are applying for associate membership.
  Check one: Yes Member Number                              No

* Please list main areas of interest in IH: