_____________________

2009 Membership Renewal & Application Form

Check One:
 Professional Membership ($40)  Student Membership ($20)
 Renewal  New Member
Please Print

Name _________________________________________________________________________
Title __________________________________________________________________________
Organization ___________________________________________________________________
Address _______________________________________________________________________
City _________________________________ State ____ Zip Code _____________________
Phone ( )_____________________________ Fax ( )_______________________________
Email Address _______________________________

NEW MEMBERS ONLY: Please complete the section below. This application is subject to approval
at the next meeting of the Board of Directors of the Indiana Healthcare Marketing and Public Relations
Society. You will be notified of the Board decision. Payment must accompany application.

Nature of Duties (please check all that apply):

Public Relations  Marketing Planning Newsletters
Other (please explain)____________________________________________________
Length of Time in Present Position ______
Previous Public Relations or Marketing Positions
Position Organization Years
_____________________ ______________________________ ____________
_____________________ ______________________________ ____________
_____________________ ______________________________ ____________

Please make checks payable to IHMPRS

Please mail the completed application form with your payment to:
Indiana Hospital & Health Association
1 American Square
Suite 1900
Indianapolis, IN 46282