IAHMR MEMBERSHIP APPLICATION

Please Complete:

Company/Organization: _______________________________________________

Mailing Address: _______________________________________________

(Street or P.O. Box)

________________________________________________

(City, State, Zip Code)

Title & Name: ________________________________________________

Telephone #: (__ __ __) __ __ __ - __ __ __ __

Email Address ________________________________________________

Note: The person listed on this application will hold the voting rights for his/her organization unless otherwise specified.

Approximately how many employees or members does your company or organization represent ______?

Will your company, department or organization require an invoice for membership fees?

Yes or No

Billing Information:

Invoicing Contact: ______________________________ Phone: __________________

Billing Address: _______________________________________________________

_______________________________________________________

Annual Membership Fees are $200.00 per organization. Please remit all payments to the Indiana Alliance of Hazardous Materials Responders at the address listed at the top of this application. Thank you.

 

Send mail to shaston@noblesville.in.us with questions or comments about this web site.
Last modified: March 27, 2009