Membership Application Are you a:*NEW MemberNEW HR Leader to HealthcareRENEWING MemberName* First Last Title*Organization*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Phone*FaxEmail* HR Membership(s):* ASHHRA SHRM Other OtherHR Certification(s) SPHR PHR SHRM-SCP SHRM-CP CHHR Other OtherApplication and payment deadline is April 30 th , 2016 or membership may be forfeited. Membership is non-transferable among members.Full Membership: Price: $50.00 Quantity: $50.00 (Each Member) Full Membership in ISHHRA shall be available to an individual who is employed by a healthcare provider in the State of Indiana, and who is actively involved in the Human Resources function of that organization.Associate Membership: Price: $250.00 Quantity: $250 (Each Member) Associate Membership in ISHHRA shall be available to those who have demonstrated an interest, or involvement with healthcare Human Resources administration, and who do not otherwise qualify for Full Membership. Associate Members enjoy the rights and privileges afforded to Full Members with the exception of the right to vote, to be an officer, or a director, and they may not use the Society’s name for materials nor presentations.Total $0.00 How would you like to pay?*PayPalMail in checkI understand that as an ISHHRA member, my contact information will be available on a members-only secured section of the ISHHRA website, and may be provided to an ISHHRA Board – approved vendor.”* I understand We are proud to process your payment using our ISHHRA PayPal account. PayPal is an internationally recognized e-commerce provider, with over 100 million members worldwide. Paying through PayPal (either with your credit or debit card) is fast, easy, and 100% secure. PayPal has very strict procedures to ensure complete e-commerce security; this protects both ISHHRA and our customers. You do not need to have a PayPal account to make a payment to ISHHRA. PayPal accepts your Visa, MasterCard, Discover, or American Express via their secure server. This iframe contains the logic required to handle Ajax powered Gravity Forms.