ONLINE MEMBERSHIP FORM
Please note: The online membership form is for new members only. Existing Members should log in to their accounts for membership renewal..
CONTACT INFORMATION
(* = required field)
Please fill out your name as you would like it to appear on your badge
*Salutation
Mr
Ms
Mrs
Miss
Dr.
Prof.
*First Name
*Last Name
*Title
Organization
*Address
*City
*State
*Zip Code
*Phone
Fax
*Email
*Badge Name
Referred By CSHSMD Member
*Password
*Confirm Password
CHOOSE YOUR CATEGORY:
CSHSMD Membership Dues Only
Annual Dues (Professional):
$100
Annual Dues (Student):
$25
SELECT YOUR PAYMENT OPTION:
Pay by Credit Card
Pay by Check
Pay by Credit Card:
Please enter your payment information below.
Credit Card Type:
Visa
MasterCard
Discover
American Express
Credit Card Number:
Name on Card:
Expiration Date:
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2012
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2015
2016
Security Code:
Complete your registration by printing out this registration page, clicking submit, then mailing a copy of your registration form along with payment to: Amy Hanzel, PO Box 12108, Charlotte, NC 28220
For more information or If you would like to pay by check please print and return with payment to:
Amy Hanzel
PO Box 12108
Charlotte, NC 28220
Email:
amyhanzel@yahoo.com
Phone: 803.412.6742