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Online Membership Renewal

2011-2012 MEMBERSHIP FORM
WHAT A BARGAIN!
Join with a non-member friend and you both pay half the regular membership fee. Memberships will not be processed until both of your forms have been received.

MEMBER DUES:
Dues will NOT be processed until payment is received at the NSLHA Office. NSLHA does not bill for dues.
Requested Membership Status* Full Member - $90
Associate Member - $87
Student Member - $40
* Recent Graduate - FREE
Life Member - FREE
** Inactive Member - $65
My membership partner is
* First year of full membership is free to recent graduates who were student members of NSLHA the previous year and are now employed.
** Not eligible for 2 for 1 deal; workshop/convention rates will be those of a non-member
MEMBER INFORMATION:
First Name, MI, Last Name*
Informal First Name*
Home Address*
City, State, ZIP*
Place of Employment*
Work Address*
City, State, ZIP*
Work Phone* ( ) -
Home Phone* ( ) -
Fax Number ( ) -
Email Address*
Position*

Employment*



If other, please specify
Send all correspondence to:* Home
Work
DEMOGRAPHIC INFORMATION:
State License* Yes
No
C.C.C.* Yes
No
Highest Academic Degree*
NSLHA Region Number*
See Regional Map
Legislative District*
COMMITTEE REQUESTS:
I would like more information on the following committee:
  Schools Committee
Nominations
Legislative Affairs
Clinical Services
Public Relations
Continuing Education
Honors Committee
Confirmation Code:
Enter the code shown in the box before clicking on submit.

Note: Fields marked by an asterisk (*) are required.