MICHIGAN ASSOCIATION OF HEALTHCARE AUDITORS Membership Application / Renewal ($45.00)
NAME: __________________________________________ DATE:_______________________ 2010
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: yes / no
Mail with your enclosed check for $45.00 payable to: MAHA
To: Mrs. Cynthia Graff
11139 Sand Crane
South Lyon, MI 48178-8520
NAME: __________________________________________ DATE:_______________________ 2010
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: yes / no
Mail with your enclosed check for $45.00 payable to: MAHA
To: Mrs. Cynthia Graff
11139 Sand Crane
South Lyon, MI 48178-8520
| Join MAHA Now |
To join, please "print page" and fill out the following form.
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