American Industrial Hygiene Association Mid-America Local Section

APPLICATION FOR MEMBERSHIP 2004-2005

Name (please print): ______________________________________________	Title: ______________________________________________
Business Affiliation:____________________________________________________________________________
Business Address: _______________________________________________	Send Mail Here?              Yes  No Use in Printed Directory? Yes  No Use in On-line Directory? Yes  No
Home Address: _______________________________________________	Send Mail Here?              Yes  No Use in Printed Directory? Yes  No Use in On-line Directory? Yes  No
E-Mail Address: _______________________________________________	Send Mail Here?              Yes  No Use in Printed Directory? Yes  No Use in On-line Directory? Yes  No
Business Phone #: ___________________________ Fax #:_____________________________________	Use in Printed Directory? Yes  No Use in On-line Directory? Yes  No

Education and Training - Please list Professional Certifications

____________________________________________________________________________________
Professional Experience - Present Duties

____________________________________________________________________________________
Membership in Other Technical Societies (please list)

____________________________________________________________________________________
Are you interested in serving on a committee? Yes  No List areas of interest

____________________________________________________________________________________
Please circle the correct response for the following:

Are you a member of National AIHA?	Yes    No
If No, are you interested in National Membership?	Yes    No
If the membership list is purchased, may we include your name?	Yes    No
Signature:____________________________________	Date:______________________________

Dues:  3-Year Membership $30 _______
           1-Year Membership $10 _______

Please return to:
Vicki Bender, 2216 SE King St, Lee’s Summit, MO 64063