Arizona Environmental Health Association Membership Application (Yearly membership runs July - June)
Applicant Information
Name:
Current Address:
City:		State:							Zip:
E-mail Address:						Receive Newsletter via E-mail? Y or N
Membership Type: New/Renewal (Please circle one)									Member #:
Regular/Student (Please circle one)				Phone: ( ) -
Employer Information
Current Employer:
Employer Address:										Contact: Work/Home ( Circle One)
City:								State:				Zip:
Business Phone: ( ) -			Fax: ( ) -
Title:
Registered/Certified? Y or N (Circle One)			Type(s):
Areas of Interest
Air Quality	Administration/Mgmt						Education
Food/Food Safety	Solid Waste						Hazardous Materials/Waste
Epidemiology	Waste Water						BioTerrorism
Water Quality	Vector/Pest Control						Committee involvement (note committee below)
Activities of Interest
Please list the types of activities or functions you would like to see offered by AEHA
Payment Information
Amount Enclosed: $					Active Member: $20.00
Cash/Check/Money Order (Please Circle One)					Student Member: $10.00
Signature of Applicant:											Date:
Referred by:________________________________ Thank you for your interest in the Arizona Environmental Health Association. We look forward to working with you in future AEHA functions. Please return application and payment to: Arizona Environmental Health Association C/O Maricopa County Environmental Services Attn: Steve Wille, AEHA Membership Chairman 1001 N. Central Ste. 300 Phoenix AZ 85004. Please make checks payable to AEHA.