Membership Application

Application 2009-2010
July 1, 2009 - June 30, 2010

*Application Type:

New Membership 
Renewal

*Member Type:

Active ($20)
Senior 65+ ($0 - no charge) 
Honorary - with board approval only
    ($0 - no charge) 
Student ($0 - no charge) 
    School Name:    
   

AHIMA ID:

*First Name:

*Last Name:

Credentials:

Title:

Organization:

*Preferred Address:

Address (cont'd):

*City:

*State:

*Zip Code:

*Phone

Home Phone

*E-mail:

Fax:

   
*Work Status

*Work Setting

Other:

*Job Type

I hereby request consideration for membership/renewal in the Southeastern Pennsylvania Health Information Management Association.

Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the refund policy, insufficient check funds policy, and the credit card terms and conditions.

*     

Payment options include credit card and check (by mail).