NHASEA Membership Form 2010-2011

Membership registration can now be completed online!

You have three payment options to choose from:

• Send a check via mail
• Request a Bill
• Request a Bill with a Purchase Order

All information is required.

*Early registration: If dues are paid on or before August 31, 2010, your name will go in a drawing for free conference registration at either the March Conference or April Law Day (member choice). Drawing will take place at the monthly meeting in September.

*Membership directory: If you would like to be included in the fall directory, please submit your membership form and check on or before September 30, 2010.

Membership Information

Name:
Title:
SAU #/ Agency:
Mailing Address:
City:
Zip Code:
Your Email:
Work Phone:
Fax:

List any Statewide Committees on which you are currently serving:
List Statewide Committees here:

List other Professional Associations you belong to:
List Professional Associations here:

Membership Type & Payment Options

Please select a membership type:

Regular Membership(Permits members to vote.) - $530.00 Regular Membership(with meeting costs for 7 meetings including lunch.) - $670.00 Associate Membership(Does NOT permit members to vote.) - $265.00 Vendor Membership(Does NOT permit members to vote.) - $530.00 Affiliate Membership(Does NOT permit members to vote.) - $000.00

Payment Choice:

I Will Mail My Payment Via Check. Please Bill Me. Please Bill Me With The Provided Purchase Order

Purchase Order #:

Payment must be received by September 30, 2010 in order to remain on the listserve.

Registration Details

If you register for a monthly meeting and reserve a lunch, we ask that you pay the $20.00 separately, with cash or a check at the door (unless you have paid all meeting costs in advance with your full membership). If you have not registered for lunch, lunch may not be available.

*Memberships are individual memberships and are non-transferable.
*Only members (regular, associate, affiliate and vendor may attend business mtgs).
*Non-members wanting to attend Professional Development session only, will be charged a guest fee of $20.00.


I agree to the terms listed on this form.

Sending Payment

Please send payment to:

NHASEA Membership
2 Pillsbury Street, Suite 500A
Concord, NH 03301

If you have any questions please call 603-224-7555 or 1-888-292-7555