NORTHEASTERN SPEECH-LANGUAGE HEARING ASSOCIATION OF PENNSYLVANIA
APPLICATION FOR MEMBERSHIP
(September 30,
2011 – September 30, 2012)
Please check all appropriate
items: ________NEW ________ RENEWAL
_____PROFESSIONAL MEMBERSHIP - Professional members hold a Masters Degree or equivalent in Speech Pathology, Audiology,
of Deaf Education. All professional members shall have the right to vote and hold office.
_____PROVISIONAL PROFESSIONAL MEMBERSHIP - Provisional Professional
members must hold a Baccalaureate degree in Speech Pathology, Audiology, or Deaf Education. Provisional Professional members
shall have the right to vote and hold office.
_____ASSOCIATE MEMBERSHIP - All persons having an interest and objectives
in this organization may elect to become Associate members. Associate membership shall not be available to individuals who
qualify for Professional or Provisional Professional membership. Associate members may not vote or hold office.
_____STUDENT
MEMBERSHIP - Student membership is available to all students carrying a minimum of twelve (12) credits per semester. Student
members may neither vote of hold office.
Enrolled at
_________________________University.
____LIFE
MEMBERSHIP – Life members must be Professional members age 62 or older with five (5) consecutive years of membership
immediately prior to age 62. Life members must be approved by Executive Council. Life members pay no yearly dues.
PSHA Membership (check
one): ___Professional Member
___Provisional Professional Member ___Student
Member
__ Not a PSHA Member
|
Name:_______________________________________________________________________________________
Mailing Address:_______________________________________________________________________________
Street
_______________________________________________________________________________
City
State Zip
Code
__________________________________
__________________________________
Phone (Circle: Home
/ Work / Cell )
E-mail (Circle: Home /
Work )
_____________________________________________________________________________
Name of Employer
Please check if applicable:
___Address
change ___Name Change
(Former Name: _____________________________________)
DUES: Make checks payable to NESHAP
Professional
dues:
$10 when postmarked by 9/30/11 - $12 if postmarked after 9/30/11
Provisional Professional dues:
$10 when postmarked by 9/30/11- $12 if postmarked after 9/30/11
Associate dues:
$8 when postmarked by 9/30/11- $10 if postmarked after 9/30/11
Student dues:
$5
RETURN TO: Eileen
Hosking Puglia 2569 Mountain Road Hamburg, PA 19562
MEMBERSHIP QUESTIONS: epuglia@comcast.net 610-562-9512
