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Dear New/Renewing CSHRM Member:

Please complete the following questionnaire and return it along with your membership dues.

Member Name: ___________________________________________________

Title: ____________________________________________________________

Employer's Name: _________________________________________________

Employer's Address ________________________________________________
(or address you would like to receive mail)

Employer's Phone: _________________________________________________

Fax Number:______________________________________________________

E-mail Address: ___________________________________________________

Areas of Responsibility: ____________________________________________

_________________________________________________________________


Signature ________________________________________________________


($100.00 for first member and $75.00 for additional members from same institution)

Committee Participation

I wish to serve/assist on the following committee(s)/activities:
(Please circle all that apply)

1. Membership Committee
2. Finance Committee
3. Education and Program Committee
4. Nominating Committee
5. Policy and Procedure Manual Committee
6. Recognition/Awards Committee

Membership Status: (Please circle choice)

1. New Member
2. CSHRM Renewing Member

Are you a member of ASHRM (American Society for Healthcare Risk Management)?_______
Are you a member of CTAHQ (Connecticut Association Healthcare Quality)?_________
Are you a CPHRM (Certified Professional Healthcare Risk Management)?__________
Are you a CPHQ (Certified Professional Healthcare Quality)?__________

Comments/Suggestions regarding Society activities:

  • Areas of special interest/suggestions for future educational programs?
      
      
  • What can CSHRM do to better serve you as a member?
      
      
  • Would you like to become actively involved in CSHRM activities?   What type of activities?
      
      
  • Are you currently serving on the Board or any committee? ______Yes ______No
    If yes, in what capacity?
  • Can you proctor/assist new members if needed? ______Yes ______No

PLEASE MAKE YOUR CHECK PAYABLE TO "CSHRM" AND MAIL TO:
($100.00 for first member and $75.00 for additional members from same institution)

Penny Cafferty
Hospital of St. Raphael
1450 Chapel Street
New Haven, CT. 06511

Please Note:
After January 31, 2008 membership fee will be $125 for first member and $100 for additional members from same institution.

 

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Connecticut Society for Healthcare Risk Management
554 Boston Post Road, Suite 147,  Orange, Connecticut 06477