National Capital Area Environmental Health Association by 8Quk68

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									           National Capital Area Environmental Health Association
                     Serving Washington DC, Northern Virginia and Maryland

                               Application for Membership
                               FY 2011 (07/01/10 – 06/30/11)
CONTACT INFORMATION
Name: ______________________________________
Address: ____________________________________
City: ___________________________ State: ________________ Zip: _____________
Contact Telephone #: __________________________
Email Address: _______________________________

EMPLOYMENT INFORMATION
Current Place of Employment: _____________________________________________
(Select one)
Local Government _____     Academia _____      Student _____
State Government _____     Industry _____      Retired _____
Federal Government _____ Private Consultant _____

MEMBERSHIP & CREDENTIALS
NEHA Member?          Yes _____     No _____
Check current credentials held:
_____ REHS/RS (Registered Environmental Health Specialist/Registered Sanitarian)
_____ CP-FS (Certified Professional – Food Safety)
_____ CEHT (Certified Environmental Health Technician)
_____ RET (Registered Environmental Technician)
_____ RHSP (Registered Hazardous Substances Professional)
_____ RHSS (Registered Hazardous Substances Specialist)

CLASSES OF MEMBERSHIP (Select one)
_____ Regular ($15) Any person who is actively employed in the field of Environmental
      Health as an Environmental Health Specialist, sanitarian, or industrial hygienist or
      who is retired from active employment in the field of Environmental Health, or
      who is a Registered Environmental Health Specialist or Registered Sanitarian
      credentialed by the National Environmental Health Association.
_____ Associate ($15) Any person who has an interest in Environmental Health.
_____ Honorary Lifetime ($0) May be conferred by the Board of Directors on any
      person for unusually distinguished achievement or service in the Environmental
      Health field. Members in this class shall not be required to pay dues.
_____ Supporting ($150) Any company, corporation or association with a general
      interest in and desire to contribute to the objectives of the Association. Members
      in this class shall not have voting rights.
_____ Student ($5) Any full-time student working towards a degree in Environmental
      Health or related field.

Send completed applications with the appropriate membership fee (payable by check or
money order to NCAEHA) to:
                            Sarah Chi, NCAEHA Treasurer
                             10777 Main Street, Suite 111
                                  Fairfax, VA 22030

								
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