SHSMD Retired Member Verification Form

Retired Member Verification Form

In order to continue in this category of membership, you must sign an official statement.

Question Title

By signing below, I affirm that I meet the qualifications for a SHSMD Retiree Membership. (Please select the options that apply to you):

I’m 55 years of age or older *required*

I’m a part-time retiree

I’m a full-time retiree

Question Title

Signature (First and Last name)

Note: SHSMD reserves the right to terminate membership without refund should we find out the information above is not accurate. If your retirement status should change at anytime, please notify SHSMD as soon as possible to avoid termination at shsmd@aha.org. By submitting this form, you agree to the rights of this statement.