Application for FMHAC Membership

Yes, I'd like to become a Member. No, but put me on your mailing list anyway

Either way, we need most of the information below to process.

Last Name: First Name: Middle Initial:
Occupation: Credentials:
Agency:
Address1:
Address2:
City: State: Zip Code:
Phone (Home): Phone (Work): Fax:
Email:

Date:

Check the appropriate box:
Regular Membership, Annual Dues: $40
Supporting Membership, Annual Dues: $100
Student, Annual Dues: $25

Check one:
Check is in the mail

Sorry, we do NOT accept credit cards at this time!
If you would rather not send the above information electronically click here to get a form you can print and fill out offline. Otherwise, submit this form and mail a check (payable to FMHAC) to the address below. You will not become a member until your payment is received, but our mailing list will be updated with your information.
Membership is valid for the calender year

Please enter comments in the space below:

Please fill in as complete as possible. If you do not submit this form you can mail the above information (with your payment) to:

FMHAC