Name: ________________________________ Email address: ____________________________________ (First) (Last) (Prefer home e-mail if available) Mailing address:_____________________________________ ______________________________________________ (MSDH employee – use complete courier address) City State Zip Phone: ________________ If MSDH employee: District # _____ Central Office: ____ APHA Member: Yes No (Daytime) (Circle) □ YES, I have received a 2014 MPHA membership card showing I am a current paid member. My 2014 Membership number is ________. You must also complete Sections B and C on reverse side to be properly registered to attend Conference. □ NO, I have not paid MPHA membership dues for 2014. (You must be a current 2014 member for Conference registration.) You must complete Sections A, B and C on both sides of this Form. □ MEMBERSHIP ONLY. If not registering to attend the 2014 Annual Conference and are ONLY Joining/Renewing 2014 membership, you may use this form and complete only SECTION A (front page) and return by mail to MPHA Membership, Post Office Box 4834, Jackson, MS 39296 or complete online at mspha.org with credit card. SECTION A MEMBERSHIP INFORMATION Membership Dues: (Check one) □ Regular $ 30.00 □ Contributing Membership $ 50.00 Type: (Check one) □ Retirees $ 15.00 □ New □ Renewal □ Students (F/T w/12 credit hours) $ 12.00 (member in 2013) □ Life Member $350.00 Section Dues: (Maximum of two sections) Joining a section is an optional component of MPHA membership. You must be a member of MPHA to join a section. Please check which section(s) you would like to join and include these dues with your MPHA annual dues (see below). All Section dues collected are returned to the section for its use. □ Environmental Health: $10 □ Nutrition: $10 □ Epidemiology: $10 □ Nursing: $10/nurses, $5/ aides/student nurses/retirees □ Health Administration: $10 □ Public Health, Education, Policy & Research, $10/regular $5/FT student □ Office Professionals: $6 □ Social Work: $8 □ Medical Care – None □ No Section Section(s) Dues Total $__________ TOTAL (Membership Dues + Section Dues) $__________ FOR CONFERENCE REGISTRATION, COMPLETE SECTIONS B AND C ON REVERSE SIDE Annual Conference Registration/Membership Form September 3-5, 2014 Jackson Hilton; Jackson, MS READ CAREFULLY & PRINT LEGIBLY