WASHINGTON STATE HEALTHCARE HUMAN RESOURCE ASSOCIATION
2005 Membership Application/Renewal
Please complete
the entire form and mail with annual dues to:
WSHHRA
c/o Carolyn Mullins
Morton General Hospital
Attn:� Human Resources
P. O. Drawer C
Morton� WA� 98356
(360) 496-5112, extension 3531
Name _________________________________�� Title _________________________________
Employer _____________________________________________________________________
Address ______________________________________________________________________
City/State/Zip _________________________________________________________________
Phone # (_____) ________________�� �Day��� �Evening��� Fax # (_____) _______________
E-mail Address: _____________________________� Web Site: _________________________
HOSPITAL/ORGANIZATION INFORMATION
FTEs ________�� Number of Employees in Organization ________�� Number of Beds ________
BRIEF DESCRIPTION OF DUTIES (if new member) _________________________________
_____________________________________________________________________________
_____________________________________________________________________________
TYPE OF YEARLY MEMBERSHIP
��Active - $75��� ��Active (2nd Person in Organization) - $50��� ��$150 total for 3 or more from same organization��� ��Consultant - $75��� ��Association - $75��� ��Student - $20
��Active - $90��� ��Active (2nd Person in Organization) - $60��� ��$175 total for 3 or more from same organization��� ��Consultant - $90��� ��Association - $90��� ��Student - $30
Are you currently a
member of ASHHRA?��� ��Yes��� ��No
If not, we encourage you to join our National Professional Organization.