Application for Membership
First Name:
Last Name:
Position/Title:
Place of Employment:
Address:
City and State:
Zip Code:
Telephone Number:
Work Fax:
e-mail address:
Home Address (optional):
City and State:
Zip Code:
Home Phone:
Home Fax:
e-mail address:
Other e-mail address:
E-mail address preferred
Work
Home
Other
Education and Training
Are you a member of the AIHA?
Yes
No
Primary Focus (Check all that apply):
Industrial Hygiene
Safety
Health
Education
Environmental
Application:
Industry
Government
Education
Consulting
E-mail us at Sharon.Holmes@na.sappi.com!!
Please complete this form, print it and mail it along with $15.00 to:
Sharon H. Holmes, CIH
Secretary DEAIHA
1329 Waterville Road
Skowhegan, ME 04976
