Mid-Missouri Health Information
Management Association (MMHIMA)
 

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Membership Application

*Required information

Demographic Information

*First Name
*Last Name
Credentials

Organization
Title
Preferred Mailing Address

Home  Work
Address
City
State
Zip Code
*Home Telephone Number
Work Telephone Number
Fax Number
Email Address

* Membership Status

Annual dues are $25.00 and must be paid by January 31 of each year, otherwise the dues are $45.00

Active Member
Associate Member
Student Member
 

Are you a previous member of Mid-Missouri Health Information Management Association?
Yes No

Are you a current member of American Health Information Management Association (AHIMA)?
Yes No

Are you a member in other professional organizations?
Yes No

* Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the insufficient check funds policy and the credit card terms and conditions.

 

If you would like a copy of this completed membership form, please print a copy before you select "continue".

Payment options include: Credit card and check
 

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Updated: 01/31/2008
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