Please Print : New Member Renewal (Member Number _________ )

Name _________________________________________________________________________________

Preferred mailing address - please indicate if the address below is Business or Residence

Address ________________________________________________________________Suite/Apt________

City ____________________________________________________ State ______ Zip-code____________

Telephone (Day) ________________________E-mail address: ____________________________________

Employer________________________________________________________________________________

Class of Membership (please check)

Active . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . $30.00
Members actively engaged in the work of a Sanitarian or Environmental Health Professional

Student . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . $20.00
                    Members actively pursuing a degree in environmental or public health or related area

Fellow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . $10.00
                    Member for at least 5 years and basic dues

Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . $300.00
                    Member for at least 5 years, application, and approval by Governing Council

Memberships are for all or part of one year and expire on Dec. 31 of each year

Signature of Applicant _____________________________________________Date ______________