Application for Membership

New Member: ________ Renewal: ________

Date: ________

Name: ________________________________________Title: ____________________

Hospital/Organization: __________________________________

Address: _______________________________________

Work Phone: __________________
Fax: __________________
Home Phone (optional): __________________
Email: ________________________

Please name the disciplines for which you recruit: ___________________________________

List highest degree and/or professional licensure: ___________________________________

Are you currently a member of NAHCR (National): Yes ___ No ___

Please select one committee on which you wish to serve:

___ Communications ___ Allied Health Recruitment ___ Bylaws

___ Membership ___ Nurse Recruitment ___ Nominations

Most recruiters fall into the "Active Membership" category and have voting rights. If you have any questions about your membership status, please contact Chastity Glover, President, NCAHCR, at 336-878-6029.

_____ Active Renewing Membership $50

_____New Members $50
_____ Associate Membership $50
_____ Honorary Membership $50
_____ Institutional Membership $200

Please enclose check payable to NCAHCR and return to the Treasurer by 1-31-08:

Tasha Bolin, Nurse Recruiter

Gaston Memorial Hospital

2525 Court Drive

Gastonia, NC 28054

Membership period January 1 to December 31

PLEASE RETURN APPLICATION AND CHECK NO LATER THAN 1-31-08.

---