ATHNA Membership Application
October 2016 - October 2017
Email address
Are you joining as a new member or renewing your membership?
First name
Your answer
Last name
Your answer
Preferred name
Your answer
Street address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Country
Your answer
Phone number
Your answer
Alternate email (optional)
Your answer
Professional Status
Practice Setting
Required
Employer
Your answer
Membership in Professional Organizations
Certifications
Years Practicing Travel Health
What social media do you use?
Would you like to be included in the ATHNA membership directory? (The directory will be available to active members only and will be password protected.)
How/Where did you learn about ATHNA?
Required
Who referred you to ATHNA?
Your answer
Membership Category
Method of payment
Name of person making payment
Would you like to receive a Certificate of Membership?
Please submit this form to receive information on how to make your payment. If you are paying by check, please include a copy of your membership form with the check.
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