To apply for membership:
| |
1. Print
and complete this form. |
| |
2. Mail
form and check payable to Gulf Coast Section AIHA:
|
| 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 |
| |
Communications (Website) |
| |
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. |