Group Membership Application

Welcome to the first step in starting a SHSMD Group Membership! SHSMD Groups consist of 10 or more members, saves your organization $35 per person, and decreases paperwork with one yearly electronic invoice or quick pay link, enclosing all members!

To apply for a SHSMD group membership, please fill out the information below for each member.

If you have any questions please contact Shavonne Hopes at shopes@aha.org.

Question Title

* 1. Organization Information

Name

Street Address

City

State

Zip

Phone Number

Fax Number

Question Title

* 2. Primary Contact Information

First Name

Last Name

Question Title

* 3. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 4. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 5. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 6. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 7. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 8. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 9. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 10. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 11. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 12. Membership Information

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 13. Need to ADD MORE members? Click here to access our document!

Please fill out the document and upload it below.

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