Full Name:  ______________________________________________________________________

Position/Title:  ____________________________________________________________________

Organization:  ____________________________________________________________________

Organization Address:  ______________________________________________________________

City:  __________________________________    State:  ____________  Zip:  ________________

Office Phone:  (______)____________________    Office Fax:  (______)______________________

Home Address:  __________________________________________________________________

City:  ___________________________________    State:  _________  Zip:  ________________

Home Phone:  (______)____________________  Email:  ___________________________________

Where do you prefer to receive society correspondence?           ______  Home      ______  Work

Are you willing to serve as a:   NCHES Chapter Officer?  ______      Committee Member? ______

Are you currently a member of the American Society for Healthcare Engineering?    ___ YES    ___NO

Please Check One                                                Make Checks Payable to “NCHES” and mail to:

______  1 Year Membership                              $50.00                             NCHES
            ______  2 Year Membership                              $90.00                             PO Box 59614
            ______  Student Membership                               *                                   Washington, DC 20012

*  Students enrolled in educational programs leading to a career in the field of healthcare engineering are
 eligible for waived fees as a student member.  Please note the institution and dates enrolled. 

Institution ___________________________________________  Dates Enrolled_______________

NCHES maintains a listing of current members and their email addresses on its website.  Please annotate
here if you object to this information being made available. 

Signed: _____________________________________________ Date: ______________________

(Do Not Write below This Line)

Check Amount: $__________          Check: # _______________                    Date Received: _________

Date Forwarded: __________          Amount Cash: __________                              Treasurer: __________