SDAIHA Membership Application 

Please print this page, complete the application,
and send it with your check to:

San Diego - A. I. H. A.
P. O. Box 910231
San Diego, CA 92191

• Check membership type:
  
  (  ) Full $30.00 - Health & Safety Professionals
  
  (  ) Associate $15 - Vendors & Related Fields
  
  (  ) Student $12 - Full time students only
  
  
• Name:___________________________________________
  
  
• Affiliation (please circle):      CIH / CAIH / CSP / CHMM / PE / Other?
  
  
• Mailing Address
  
  Street:__________________________________________
  
  City:____________________________________________
  
  Zip:______________
  
  
• Employer:_______________________________________
  
  
• Office Phone: (       )___________-______________
  
  
• Home Phone: (       )___________-______________
  
  
• E-mail :______________________@_______________________
  

• May we post it on our Web Site "Membership"page?:    Yes  /  No
  
  
• Are You A Member Of The National A.I.H.A.?     Yes  /  No
  
  
• What Other Professional Associations Do You Belong To?
  
          1._________________________________________
  
          2._________________________________________
  
          3._________________________________________
  
  
• Are you interested in "Expertise Sharing?"  Yes  /  No
  
  
• Are you interested in supporting and/or teaching annual
  SD - AIHA /ABIH review courses?   Yes  /  No

Thank you for registering!