www.tshrm.org
Application for Membership (Initial or Renewal)
Please type or print clearly
DATE: ____________________
NAME: ____________________________________Professional designation: ________________________
TITLE: _____________________________________________________________________________________________
PRESENT EMPLOYER:
___________________________________________________________________________
ADDRESS c
Business c
Home: ____________________________________________________________________
(Preferred mailing address)
CITY:
________________________________________________________ STATE:
_________ ZIP: ______________
OFFICE PHONE: _____________________________________ FAX:
_______________________________________
EMAIL ADDRESS: ________________________________________________________________________________
PLEASE CHECK THE
APPLICABLE CATEGORY: c NEW MEMBER
c RENEWING MEMBER Membership is open to those persons whose job responsibilities include
healthcare risk management or who have demonstrated a bonafide interest in the
field of healthcare risk management and who agree to support the mission,
goals, and objectives of the society.
If you are a renewing member, please indicate the number of years as a member _____________
Are you a member of ASHRM? c Yes c No
Please list current job
responsibilities:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
TSHRM SUB-CHAPTER: c
The TSHRM annual membership
period extends January - December. (Memberships are not pro-rated & are
non-transferable.)
Dues: $50.00 All
checks payable to: TSHRM
Please submit the completed
application and check by
Laura Zamata, TSHRM Treasurer
West Tennessee Healthcare
1804 Hwy. 45 Bypass,
For questions, please call or e-mail: (731) 660-8753; laura.zamata@wth.org