GEORGIA ENVIRONMENTAL HEALTH ASSOCIATION
APPLICATION FOR MEMBERSHIP

New Member:    _____
Renewal:            _____

DATE:                          

NAME:                                                                     

HOME ADDRESS:                                                                                              
                                    Number               Street                                           Apt. #                                  
                                                                                                                                
                                   City                     State                                                Zip

HOME PHONE:                                                                       
BUSINESS PHONE:    ______________________________

JOB TITLE:  _____________________________________

BUSINESS ADDRESS:                                                                                    

                                                                                                                           

Please check the appropriate membership status for July 1, 2002 through June 30, 2003. Active Member ( ) $25.00
Associate Member ( ) $25.00
Honorary Member ( ) $0
Student Member ( ) $1.00

Active Members are those that are employed at or retired from jobs that involve environmental health as a major component of their occupation.
Associate Members are typically those who provide products for use in environmental health related activities, but an associate member may be anyone with an interest in environmental health issues.
Honorary Member is bestowed upon members by the Awards Committee.

Voting privileges in the Association shall be limited to Active Members and Honorary Members only.

Please send application and check (made payable to GEHA) to: 
Georgia Environmental Health Association 
Golden Isles Parkway Rte 2, Box 1140 Hawkinsville, GA 31036