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Member Application - Organization
MEMBER INFORMATION
*
First
*
Last
Title
*
Company
*
Address
*
City
*
State
AK
AL
AR
AS
AZ
CA
CO
CT
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DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
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MD
ME
MH
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MN
MO
MP
MS
MT
NC
ND
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NJ
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OH
OK
OR
PA
PR
PW
RI
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SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
*
Zip
*
Phone #
Fax #
*
E-mail
Website
*
Are you currently a member of ASHHRA?*
--Please select--
No
Yes
*If not, please consider joining our national professional organization (
www.ashhra.org
)
HOSPITAL/ORGANIZATION INFORMATION
Number of FTEs
Number of Employees
Number of Beds
Description of Duties
Organization Type
Clinic
Hospital
Hospital System
Long-Term Care
Specialty
Business Partner
*
How many individuals are you signing up from your organization?
1 Individual from an Organization - $75
2 Individuals from an Organization - $125
3-4 Individuals from an Organization - $150
5-10 Individuals from an Organization - $300
10+ Individuals from an Organization - $500
