IHA Membership Application

After we receive this form, you will be billed for the appropriate amount.

Please enter the following:

* Full Name
First Name
Middle Initial
Last Name
Organization Name
Address
Address
City
State
Zip
* Bus./Day Phone
Extension
* E-mail Address
Home Phone
Fax
Membership category INDIVIDUAL $30.00 INSTITUTIONAL $35.00 CORPORATE $75.00 GOVERNMENTAL $100.00 ADVISORY $100.00
Additional Contribution
Total Amount
* Verify