American Industrial Hygiene Association

Sacramento Valley Section
Dues Notice AND
APPLICATION for MEMBERSHIP

Already a member? You can view the section roster using the link and the password. If you need to correct any information, you can use the form below and note that you are updating information.

Dear Member :

Your annual membership dues for 2011 need to be paid by March 1st. After March 1st, any person who has not paid their dues will no longer be a member in good standing until their dues are paid. In order to avoid any lapse in your membership, please promptly return this notice to the Treasurer along with a check for the appropriate fee made payable to AIHA-SVS to:

roman.worobel-at-aecom.com

We have also posted a Acrobat PDF version and a MS WORD version which you may print and send with your dues payment.
If you are aplying for an "ORGANIZATIONAL MEMBERSHIP", please use the PDF or Word form.

The purpose of this form is to update my information - or - submit a New Application

Name:

Title (if appropriate):
(e.g. CIH, CSP, IHIT, OHST, CHST, STS, etc.)

Please indicate where you would like your mailings sent: Select one Work Home

Work Address:

Phone:
Home Address: (use as many lines as you wish)

Phone:

Please indicate where you would like your e-mail and newsletters sent: Select one Work Home

Work E-mail address:
Home E-mail address (loginname@domain.name):

Please tell us a bit about your background (for new applicants)

Degree: College:

Degree: College:

Degree: College:

Are you a National member of AIHA? Yes No
If not, you may call (703) 849-8888 to obtain an application. If yes, please give you member number (if you know it):

List memberships in other technical societies::

For which category of membership are you applying? Full ($30) Student ($5) Retired (N/C)

In an effort to reduce costs the newsletter is on our web site,
but can be sent by: e-mail fax regular mail

Are you interested in : Arranging for a speaker at a meeting
Helping out with the Symposium
Community outreach projects
Helping out with Vendor's Night
Contributing an article to the Newsletter
Other - contact me

Comments:

If this is a new application, we will contact you about your application after reviewing it.

Roman Worobel, CIH
131 Coloma Way
Sacramento, CA 95819
916-361-6429
email: roman.worobel-at-aecom.com

The Tax Identification Number for AIHA/SVS is: 94-2666299

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The purpose of this form is to update my information - or - submit a New Application
Name:
Title (if appropriate): (e.g. CIH, CSP, IHIT, OHST, CHST, STS, etc.)
Please indicate where you would like your mailings sent: Select one Work Home
Work Address: Phone:	Home Address: (use as many lines as you wish) Phone:
Please indicate where you would like your e-mail and newsletters sent: Select one Work Home
Work E-mail address:	Home E-mail address (loginname@domain.name):
Please tell us a bit about your background (for new applicants)
Degree:	College:
Degree:	College:
Degree:	College:
Are you a National member of AIHA? Yes No If not, you may call (703) 849-8888 to obtain an application.	If yes, please give you member number (if you know it):
List memberships in other technical societies::
For which category of membership are you applying?	Full ($30) Student ($5) Retired (N/C)
In an effort to reduce costs the newsletter is on our web site, but can be sent by:	e-mail fax regular mail
Are you interested in :	Arranging for a speaker at a meeting Helping out with the Symposium Community outreach projects Helping out with Vendor's Night Contributing an article to the Newsletter Other - contact me
Comments:

American Industrial Hygiene Association

Sacramento Valley Section Dues Notice AND APPLICATION for MEMBERSHIP

Sacramento Valley Section
Dues Notice AND
APPLICATION for MEMBERSHIP