To apply for membership:
|
1. Print and complete this
form. |
|
2. Mail form and check
payable to Gulf Coast Section AIHA: |
|
Amy Reiter
5931 Mettler Lane
Richmond, TX 77469
Phone: 281-239-2590
gcsaiha@yahoo.com |
|
| If you need a receipt, please make
a copy of the completed form. |
Name: _______________________________ Job
Title:___________________
Affiliation/Business:________________________________________________
Preferred Mailing
Address:___________________________________________
City: _______________________ State: ___________ Zip:
________________
Telephone: Daytime (_______)___________ Fax
(_______)______________
Email _______________________________________
Professional Certifications: [ ] CIH [ ] CSP [ ]
Other (please specify):_______________
Are you a National AIHA member? [ ] No [ ] Yes Member
#:_______________
Would you like to participate in the following committees or
activities?
| |
Program Committee (for meetings) |
| |
Continuing Education Committee |
| |
Newsletter |
| |
Regulatory Affairs Committee |
| |
Public Affairs Committee |
| |
Membership Committee |
| |
Speaker’s Bureau |
| |
Science Fair Judge |
Gulf Coast Section Dues (check one):
| |
Regular membership $15.00 |
| |
Full –time Student membership $5.00 |
| |
Retired membership (no fee) |
Signature:_______________________________Date:_________________
Dues
received after September 1 are applied to the following year. The Gulf
Coast Section dues may not be deductible as a charitable contribution for
federal income tax purposes, but may be deductible as a business expense.
Consult your tax advisor for assistance with questions. |