Membership Application - Join the SHRM Emerald Coast Chapter

Membership Application
SHRM/Emerald Coast and
Walton County Area Chapter #459
Attn: Teresa Kaliski, PHR
P.O. Box 5579
Fort Walton Beach, FL 32549-5579

Please follow the procedures below when completing the membership application. If you have any questions, please contact Teresa Kaliski, PHR at 650-9935, Ext. 20 or by email at tkaliski@simplehr.com

Input full first name
Input last name
Input current employer name
Input current title that you hold
Input business address
Input city, state & zip code
Input business phone number
Input business fax number
Input correct email address
Input the number of years in profession
Brief summary of your current job duties
Agree or Disagree
Input date of application
Type of memberships:
Regular: Professional in the field of Human Resources or Bona fide interest in Human Resources
Student: College student
Membership year runs from April 1st to March 31st, pro-rated on a quarterly basis.
SHRM National Members, please apply a 10% discount of local membership
Input any HR Certification that you currently hold
Input yes or no as to volunteering on SHRM committees
Input Okaloosa or Walton County on where you prefer to attend meetings
Type in the person you were referred to SHRM-ECC by
Click submit

Note: Please submit your application online and mail your membership dues to the P.O. Box address provided. Your application will be forwarded to the Director at Large, Memberships for approval. Once you are approved for membership, the director will generate a welcome email to you!

*First Name	*Last Name

*Company Name	*Title

*Business Address	*City	*State & Zip

*Phone	*Fax

*Email Address	*Number of Years in Professional Work
		(Exempt Duties, Teaching, or Consulting in field)

*Describe your present job duties

I hereby certify that the information provided above is true and accurate.
*Agree	Yes	No	*Date

Please check type of membership sought: (Membership year runs from April 1^st to March 31^st) Pro-rated Quarterly
			Annual	Jul-Mar	Oct-Mar	Jan-Mar
	Regular	Professional in the field of Human Resources or Bona fide interest in HR	$50.00	$37.50	$25.00	$12.50
	Student	College Student without National SHRM Membership *No cost for students with National SHRM Membership	$25.00	$18.75	$12.50	$6.25
	*School*
	*Field*

* Are you a member of National Society for Human Resources Management? There is a 10% discount for national members.
	Yes	No	Membership#

* Do you hold any professional certifications?
	Yes	No	Type

* Are you interested in volunteering for any of the committees?

Yes

If yes, which committee do you prefer?

* Where do you prefer to attend meetings?

Okaloosa

Walton

Referred by

	Copyright � 2003-2011 The Society for Human Resource Management Emerald Coast Chapter #459 P.O. Box 5579 Fort Walton Beach, Florida 32549-5579 Email: info@shrm-emeraldcoast.org
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