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AIHA - MANITOBA NEW MEMBER APPLICATION AND MEMBER UPDATE FORM

Note: Your 2013 membership will expire January 31, 2014

Please fill out this form and return it to the Membership Committee, along with your $20 membership fee. The following information is required to maintain the Section's mailing list, used for distribution of meeting notices, minutes, course announcements and similar materials. A Membership Directory is provided to promote communication and participation among members. Please advise the Membership Committee of any change to your address, telephone number or e-mail address.

Name: ____________________________________________________________________________

Employer: __________________________________________________________________________

Position: ___________________________________________________________________________

Mailing Address: Work Home __________________________________________________________

Home Phone: _______________________________________________________________________

Work Phone: _______________________________________________________________________

Fax Number: _______________________________________________________________________

E-mail: ____________________________________________________________________________

Have you formerly been a member of AIHA Manitoba? Yes ____ No ____
If yes, what was the last year you were a member?  __
Are you currently a National AIHA member? Yes ____ No ____
Would you like information on National AIHA membership? Yes ____ No ____
Would you like to be listed in the AIHA - MB Membership
Resource Bank (in the printed Membership Directory**)? Yes ____ No ____
If yes, list appropriate Resource Bank Category numbers (see the list below):

** AIHA - Manitoba has also developed a Resource Bank listing for its web site. If you wish to be listed, please sign the consent section below. No member listing to the web site will be made unless this additional consent has been provided by the prospective member.