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WSHHRA MEMBERSHIP ON-LINE APPLICATION

Name *

Organization

Title *

Address *

City/State/Zip *

Phone *

Phone Type

Office
Mobile

E-mail Address: *

Fax

Website

Are you a member of ASHHRA *

Yes
No

Number of FTEs

Number of Employees

Number of Beds

Brief Description of Duties

Organization Type *

Clinic
Hospital
Hospital System
Long Term Care
Speciality
Business Partner
Other (Please Explain)

Other Explanation

Annual Membership Dues *

One Individual from an Organization: $75
Two Individuals from an Organization: $125
2-4 Inidividuals from an Organization: $150
5-10 Individuals from an Organization: $300
10+ Individuals from an Organization: $500
Business Partner: $50
Student: $20
Emeritus: $0 (If Approved by Board)

Payment *

PayPal
Check

Name on Payment Credit Card

* Required

*Membership is owned by the member and not the employer, therefore if a member changes organizations, it will follow the member.