HPRMA

First Name:

Last Name:

Email Address:

Organization:

Address:

City:

State:

Zip:

Phone Number:

Fax Number:

Credit Card Type:

Paying by check? Download & mail form.

Card Number:

Exp Date:

/ MM/YYYY

CCV/Security Code:

Membership Fee:

* If you are a new member, please answer the following Questions:

How long have you been in your current position?

Would you describe your job as primarily:

PR	Marketing	Advertising
Planning	Business Development	Vendor Serving Healthcare Industry

What value do you expect from HPRMA membership?

What ideas, special skill or value can you contribute to this organization?

Please select a committee on which you are interested in serving:

Do you have resources you can donate/share with the organization (e.g. mailing services, printing services, research, graphic design, etc.)?

* New applicants only, please complete the following:

How many years in the profession?

0-2

2-5

5-10

10+

Current job responsibilities:

Position to which you report:

Position(s) which report to you:

Undergraduate degree/major:

Graduate degree:

Postgraduate degree:

Currently full- or part-time student? Where?

Other professional memberships:

Referred by:

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