MICHIGAN ASSOCIATION OF HEALTHCARE AUDITORS            Membership Application
                                                                                                          / Renewal 

NAME:                                                                               DATE:______________ 2008

MAILING ADDRESS:                                                                

                               ____________________________________     Circle:   home      work                                                                                                                                   
WORK PHONE____________________  WORK FAX ______________________________

WORK EMAIL:______________________________

HOME PHONE:____________________       HOME FAX:___________________

HOME EMAIL _____________________________    CELL PHONE ___________________

BIRTHDAY (Month & Day Only):                               

WORK AFFILIATE NAME / CITY  :                                                                            

JOB TITLE:                                                                                                  

 LICENSURE, DEGREES AND  CERTIFICATES OBTAINED: 

  ___   Registered Nurse                 ___ Master of Business       ___ RHIT        ___   MSN

  ___  BSN                                  ___  Master of Science        ___  RRA       ___   A.D.

  ___  Bachelor of Science            ___  LPN                            ___  CMAS    ___   LNCC

   Other  _____________________________________________                           

  I AM INTERESTED IN BEING A MENTOR  ________

  I AM INTERESTED IN PARTICIPATING IN THE FOLLOWING COMMITTEE:____________________

  I AM INTERESTED IN SEEKING A POSITION ON THE BOARD OF DIRECTORS  ________

_____________________________________________________________________________________________ 

  For more information please contact the president, Donna Bauby at:
     don1205@asugroup.com         517-861-7314