2023 IHAA Membership Form

Membership Application / Renewal Form

2023
Choose one*

I am renewing my membershipI am a new member
Name*

First NameLast Name
Professional Creditionals:
(e.g., ACA, HIS-BC)
I am licensed in the following States:
Company Name*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Home Number*

Area CodePhone Number
Cell Number

Area CodePhone Number
Work Number*

Area CodePhone Number
Website
Choose a Membership Level
prevnext( X )
1 Year Regular Membership$150.00

1 Year Associate Membership$525.00

1 Year Affiliate Membership$75.00
I agree to abide by the IHAA By-Laws and Code of Ethics
Should be Empty: