CHMM-MI Membership Application

CHMM-MI Membership Application

Name:*

Email:*

Company:

Title:

Preferred Address?

Home Business

Home Address:*

City:*

Zip Code:*

Home Phone*

Business Address

City:

State:

Zip Code:

Business Phone:

Fax:

How did you hear about CHMM-MI?

Have you ever attended a CHMM-MI event?

Yes No

If you answered, yes, what was it? Check all categories attended.

Business Industry Legal Education Government

Professional Certifications held:

Are you interested in presenting at the Review Course?

Yes No

If you answered, yes, please list Area(s) of Expertise:

Certification Number:

Check One:

Voting Member (Must be CHMM Certified and ACHMM member) $30/Calendar Year (List certification number above.)
Non-voting Member $30/Calendar Year (List certification number above.)
Full-time Student Member $10/Calendar Year