NORTHEASTERN SPEECH-LANGUAGE HEARING ASSOCIATION OF PENNSYLVANIA

APPLICATION FOR MEMBERSHIP

(September 30, 2009 – September 30, 2010)

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 9/30/09 - $12 if postmarked after 9/30/09

Provisional Professional dues:          $10 when postmarked by 9/30/09 - $12 if postmarked after 9/30/09

Associate dues:                                   $08 when postmarked by 9/30/09 - $10 if postmarked after 9/30/09

Student dues:                                       $03 when postmarked by 9/30/09 - $05 if postmarked after 9/30/09

RETURN TO: Eileen Hosking Puglia   2569 Mountain Road   Hamburg, PA 19562

MEMBERSHIP QUESTIONS: epuglia@comcast.net    610-562-9512