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Please print this page and complete the requested information Name:_________________________________________________________ Title:__________________________________________________________ Facility:________________________________________________________ Address:_______________________________________________________ City:______________________________ State:_______ Zip:___________Telephone#:_________________________ Fax#:_____________________E-mail:________________________________________________________ Adm. License #:_________________________________________________ Home Address:__________________________________________________ City:______________________________ State:_______ Zip:___________ Telephone#:_________________________ Fax#:_____________________ Other E-mail:___________________________________________________ Membership type (check one): New Active Membership pro-rated one time only, if joining during q ($75 2nd Quarter) OR q ($50 after July 1st) Membership expires December 31st of each year q My check made payable to INHAA is enclosed. Credit Card Payment: q MasterCard q Visa Print Cardholder name:____________________________________________ Credit Card #:___________________________________________________ Exp. Date:______________________________________________________ Signature:______________________________________________________ Mail payment to: |
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Updated: 05/15/07 |