ASHHRA Logo

American Society for Healthcare Human Resources Administration

Last updated: January 2015

APPLICATION FOR MEMBERSHIP
AMERICAN SOCIETY FOR HEALTHCARE HUMAN RESOURCES ADMINISTRATION (ASHHRA)

* Required Information

Employment Information:
*Prefix
*First Name
MI
*Last Name

Certifications: CHHR PHR SPHR GPHR Other
*Company/Institution
*Title
*Street Address
*City
*State
*Country
*Zip Code
*Phone  xxx-xxx-xxxx
Fax  xxx-xxx-xxxx
*E-mail 
*Years in healthcare HR profession

Personal Information:
Street Address
City
State
Country
Zip Code
Phone  xxx-xxx-xxxx
Fax  xxx-xxx-xxxx
E-mail 
Date of Birth (optional):

Business address Home address
Check if you do not wish to receive non-association mail

Are you a member of your local ASHHRA Chapter?
Yes, chapter name
No


Demographic Information: Please provide the appropriate code for each category
EDUCATION
High School   Some College beyond Bachelor's Degree  Doctorate 
Some College  Master's Degree   
Bachelor's Degree  MBA    

RACE/ETHNIC IDENTIFICATION
Multi-Cultural African American  Other 
American Indian/ Alaskan Native Hispanic   
Asian/Pacific Islander   Caucasian   


Gender 
Male 
Female 


DEPARTMENT SIZE 
Less than 10 employees  25-49 employees  100 or more
10-24 employees  Over 50  

COMPANY SIZE
Less than 100 employees 1,000 - 2,499 employees 10000 - 24999 employees
100 - 499 employees 2,500 - 4,999 employees more than 25000 employees
500 - 999 employees 5,000 or more employees  

YOUR FUNCTION
HR Generalist Legal Research
Employment/Recruitment Health/Safety/Security Consultant
Benefits Employee Assistant Programs Administrative
Compensation Employee Relations International HRM
Labor/Industrial Relations Communications Diversity
Training/Development EEO/Affirmative Action Organizational Development
Other: Please specify HRIS


Type of Organization 
Hospital / Health Care System 
Health Care Organization Outside of Hospitals 

ASHHRA membership only
Student
Granted to current full-time students who carry at least 20 hours a semester (must provide a transcript and student ID) and work less than 30 hours a week.
Retired
Granted to former health care HR practitioners and consultants that have retired from the field.

Individual Membership
ASHHRA Student Membership $50
ASHHRA Retired Membership $50

Corporate Membership (for practitioner members only)  
Category I: Organizations with up to five members $750
Category II: Organizations with 6 – 10 members $1250
  Category III: Organizations with more than 10, call us at 312-422-3720 TBD

* Please indicate your method of payment:
Credit Card (A message will be sent to the purchaser contact information provided below with instructions for completing your transaction by credit card.)

Purchaser Information
*Prefix:
*First Name:
*Last Name:
Title:
*Street Address:
*City:
*State:
*Country:
*Zip Code:
Phone #:  xxx-xxx-xxxx
Fax #:  xxx-xxx-xxxx
*E-mail:
*Re-enter e-mail address:

If paying by check or money order, please print this order form and mail to address supplied below. Remittance of dues must accompany this application. Make check or money order payable to: American Society for Healthcare Human Resources, American Hospital Association, P.O. Box 75315, Chicago, Illinois 60675-5315.

I hearby apply for membership in the American Society for Healthcare Human Resources Administration. I agree to pay the current applicable membership dues.

Name

Dues are not deductible as charitable contributions for federal income tax purposes but may be deductible as ordinary and necessary business expenses.


155 N. Wacker, 4th Floor
Chicago, IL, 60606
Phone - 312/422-3720
Fax - 312/422-3609
Email - ashhra@aha.org