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
Education and Training
Are you a member of the AIHA?
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