National Organization for Human Services
5341 Old Highway 5, Ste 206, #214, Woodstock, GA 30188
770-924-8899  FAX 678-494-5076  www.nationalhumanservices.org
Membership Application and Renewal Form
Type:  New Member
 Renewal Membership No. _________ (printed on your mailing label)
Category:  Regular $95
 Student $35
 Retired $60
 Organization $190*
 Additional Organization Member **
Please note Membership Fees are non-refundable.
*Organizational Membership provides for TWO individual memberships.
Copy this form to provide information for second member.
** Please give primary Organization Member’s name or organization: _______________________
Member Information:
First Name: __________________________ MI: __________ Last Name: ________________________________________
Position: __________________________________________ Institution: _________________________________________
Referred by: _________________________________________________________________________________________
Primary Address (for membership mailings, newsletters, etc.):
Address: _________________________________________________________________________________________
City: ________________________________________ State: __________ ZIP: ________________________________
Secondary Address:
Address: _________________________________________________________________________________________
City: ________________________________________ State: __________ ZIP: ________________________________
Note when to use Secondary Address (example: Use June-August): ___________________________________________
Work Telephone: __________________________________ Home Telephone: _____________________________________
Fax: ____________________________________________ Email: ______________________________________________
Students: Expected Grad Date: ______________________ College: ____________________________________________
What is your preferred method of communication?  Mail
May NOHS send you email?  Yes
Payment:
 Check enclosed
 No
 Email  Fax
May NOHS send you faxes?  Yes
 No
 VISA  MasterCard
Card #: ____________________________________ Exp ______________ Cardholder ZIP Code: ____________________
Name on Card: ______________________________ Signature: ________________________________________________
Mail to: National Organization for Human Services
5341 Old Highway 5, Ste. 206, #214
Woodstock, GA 30188
or fax to: 678 494 5076