Michigan Industrial Hygiene Society Membership Renewal Request Form Membership dues for the upcoming year are payable between September 1 - November 30 for current members. The MIHS Board has voted that a $5.00 late fee will be applied for dues paid after December 1 (Note: Dues paid prior to September 1 are for the current year only and will be due again during the next dues period). Please select your membership status and provide the information at the bottom of this form. Indicate your name and complete only those portions of the form which have changed since the last membership year. Please print the completed form for your records and mail a photocopy with you remittance (see instructions below if using Pay Pal to pay Online). Cost Membership Description of Membership Status $50 Organizational Company published as sponsor in Membership Directory and Mini Conference Program $25 Full Member in good standing with AIHA $25 Associate Any person having a professional interest in Industrial Hygiene $5 Student Graduate or undergraduate student enrolled in occupational or environmental health studies. Persons employed full-time are not eligible for this membership category regardless of their studies. Offline Membership Renewal Form   This form is for those paying with a check. Please print the completed form for your records and mail a photocopy with you remittance.  You will be notified upon acceptance of your application. You may also complete the Online form below and during the checheckout process select Offline payment and follow the instructions. > Offline Renewal Form (printer friendly- opens new window) Online Membership Renewal Form   Renewing Members: Use this form to renew membership If you are renewing your membership complete this short form. Please provide any new contact information or changes in your membership status (new certifications, etc.) as indicated on the form.

*What is your E-mail address? *Required Enter your contact information below: * Name: IH Designation: (CIH,CSP, etc. - Please limit to your primary) My contact and other information remains the same. IF REQUIRED, please make any changes in the form fields below (do not check above). Title: Company: Address: Work Home    Address 2: City/State/Zip: Phone:   Work Home  Fax Number: Additional Information: Comments: Membership Level: *Type of Membership: Select One Full Membership - $25 Associate Membership - $25 Student Membership - $5 Organizational Membership - $50   Honorary (send form, dues are waived) Life (send form, dues are waived) The following information is optional - select only if changes have occurred: Which of the following certifications do you hold? (check all that apply) CIH CSP CHMM IHT OHST PE Other: (please list - do not include 40 hr. training classes) Which related organizations are you a member of? WMIHS ASSE SOT OPA (DRS) ACGIH APCA APHA AOHN (NURSES) Other: (please list) Which of the following committees do you have an interest in? Awards International Newsletter  Community Outreach Legislative Nominating  Continuing Education Membership Publicity Program and Arrangements

MIHS promises not to use this information in any manner inconsistent with the purpose intended. We will require your E-mail address to contact you with assistance.  Payment Options: Credit Cards or Checks Online - We accept Visa, MasterCard, Discover, American Express, or Online Checks our secure Pay Pal account. Upon completion and submittal of the above form you will routed to a page with a link to our new Shopping Cart, select the type of membership you are requesting and follow instructions to checkout. If paying by PayPal, have your log-in information and password ready before connecting to the PayPal site. You do not have to be a PayPal member to utilize this feature. . Checks by Mail - Please print and forward completed form with remittance to: MIHS Aaron Jacobs Attention: MIHS 46400 Continental Drive Chesterfield, MI 48047  E-mail: info@MIHSweb.org