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