Membership Application

Membership Information *

Standard Membership ($105)
Student Membership ($70) Full-time
Senior Membership ($70) 65 and Older

Health Ministries Role

Select your Primary Role: *
	In what state are you licensed?
Select your Secondary Role:
	In what state are you licensed?

Current Licenses

ANP	RN	LPN
CP	MD	MSW
Other

Personal Information

Title:
First Name:*
Middle Initial:
Last Name:*
Address:*
City:*
State:*
Zip Code:*

Primary Phone:*
Secondary Phone:
Email Address:*
Confirm Email:*
Password:*
Confirm Password:*

Primary Location of Practice : *

(Organization / Employer)

Secondary Location of Practice:

(Organization / Employer)

Faith Group & Denomination: *

Faith Group		Denomination/Sect
	Christian
	Jewish
	Muslim
	Hindu
	Other

Do you wish your contact information to be shared for the purpose of HMA related activities? * Yes No
(i.e. networking opportunities, educational opportunities, leadership opportunities, etc.)