Date:

Please check one:  New Member Application     Membership Renewal

First Name*:   Last Name*:

Degree(s):

Title*: Organization Name :

Work Address Line 1: Address Line 2:

City: State: Zip:

Work Email Work Phone Fax Number

THPA sponsor for new member (optional)

Name*: Office Address

Note to state employees

Your membership in TPHA is independant of employment by the State Department of Health. the following information will be used as your contact information, including the Newsletter.

Address Line 1: Address Line 2:

City: State: Zip:

Home Phone Home Email

Senate District # House District #

Please check below the section in which you wish to become a member. Joining a section is optional and you are eligible to join only one section

Case Management (Section dues $10.00 annually)
Communicable Disease
Dental
Emergency Preparedness
Enviromental (Section dues $20.00 annually)
Epidemiology & Biostatistics
Health Administration
Health Education / Health Promotion
Management Support (Section dues $10.00 annually)
Nursing (Section dues $10.00 annually)
Nutrition (Section dues $5.00 annually)
Physicians
Students

Payment Information

Individual Membership Fee $30.00
Section Dues (see above)
Student Membership
Renewal Late Fee (after 3/15)