ILLINOIS NURSING HOME ADMINISTRATORS ASSOCIATION



478155-15557500ILLINOIS NURSING HOME ADMINISTRATORS ASSOCIATIONNew / Renewal Membership ApplicationJanuary 1 – December 31, 2021Administrators and Nurses can obtain quality professional education at a great value – $125.00 annual membership fee! You will receive information on upcoming educational events, the Administrator’s Advocate monthly newsletter, and will have the opportunity to network with some of the friendliest and most dedicated professionals in the field. If the administrator of the facility is an INHAA member, additional staff can attend the INHAA conferences at the member rate providing the administrator includes each staff member on his/her registration form. All must register on the same form to receive this discount. Sign up today! It is important to complete the information below, so that we have updated records for each member. Please send this form along with your payment for INHAA Membership 2021. INHAA FEIN #37-1219674.PLEASE PRINT (Please include preferred E-mail address for INHAA newsletter and updates)Name: ____________________________________________ Title: ___________________________________________E-mail:_____________________________ Phone: _____________________________ Fax:__________________________________Facility Name: ________________________________________________________________________________________________Facility Address: _____________________________ ____ City, State, Zip______________________________________Home Address: ___________________________________ City, State, Zip _____________________________________Administrator License #: ____________________ ________Nurse License #: ___________________________________Check: ______ Credit Card: ______ Visa______ Master Card only – (NO AMEX)Credit Card Number: Exp. Date: ______________________________Cardholder Name: _ ______________________________Cardholder Address:__________________________________Signature_______________________________________________ Date:______________________________________Please send form with check payable to: INHAA or credit card information to PO Box 272, Rochester, IL 62563; email vwiltsie@, fax 708-248-8078Thank you for your support of INHAA! Check all that apply:Primary Position/StatusFacility Type_____Administrator_____SNF_____Nurse_____ICF/DD_____Consultant/Vendor (describe)_____Assisted Living_____Working in another capacity (describe)_____Assisted Living/Memory Care_____Active_____Supported Living_____RetiredAre you interested in being a presenter for an educational session/seminar?_____Yes_____NoIf yes, please identify the topic and attach a brief description, along with your resume. ................
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