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WSHHRA MEMBERSHIP ON-LINE APPLICATION

Name *

Title *

Address *

City/State/Zip *

Phone *

Phone Type

Office
Mobile

E-mail Address: *

Fax

Website

Are you a member of ASHHRA *

Yes
No

Number of FTEs

Number of Employees

Number of Beds

Brief Description of Duties

Type of Annual Membership *

Active Before March 31: $75
Active (2nd Person in Organization) Before March 31: $50
Up to 4 From Organization Before March 31: $150
5-10 From Organization Before March 31: $300
More than 10 From Organization Before March 31: $500
Student Before March 31: $20
Active After March 31: $90
Active (2nd Person in Organization) After March 31: $60
Up to 4 From Organization After March 31: $175
5 - 10 From Organization After March 31: $350
More than 10 From Organization After March 31: $600
Student After March 31: $30

Payment *

PayPal
Check

Name on Payment Credit Card

I approve WSHHRA to list my information in a Membership Directory accessible to members via the Internet. *

Yes
No

I approve my e-mail address to be listed in the Membership Directory that will be posted on the internet and available to WSHHRA members who may use the e-mail address in a listserv. *

Yes
No

* Required