MINNESOTA SPEECH-LANGUAGE-HEARING ASSOCIATION
1000 Westgate Dr. Suite 252 • St. Paul, MN 55114
Phone: 651.290.6292 • Fax: 651.290.2266 • E-mail: office@msha.net • Web: www.msha.net
Membership Application
2
7
0
Instructions: Complete all pages and remit it to the MSHA office by fax or mail with payment. You can also join online at
www.msha.net
Annual dues apply for one year from date of joining.
APPLICANT’S CONTACT INFORMATION
Name
(AS YOU WOULD LIKE IT PUBLISHED; INCLUDE DESIGNATIONS/ SUFFIXES)
Employment Information
EMPLOYER
JOB TITLE
MEMBERSHIP INCENTIVE DISCOUNTS
Group 1: 5-10 members ($5 discount from each membership)
Group 2: 11 or more members ($10 discount from each
membership)
Group discounts can not be applied to student, associate, affiliate
or life memberships.
Two-year membership 10% discount from regular
membership/$20 discount – must submit in single payment
Can’t be combined with group discount.
ADDRESS
PREFERENCES
CITY
STATE
ZIP
E-MAIL ADDRESS
Home Information
MSHA mail delivery
Work
Home
MSHA e-mail delivery
Work
Home
Member directory listing
Work
No listing
Do not send me any non-MSHA mail or e-mail.
ADDRESS
CONTRIBUTIONS
CITY
STATE
ZIP
E-MAIL ADDRESS
Phone number (please provide at least one)
WORK PHONE
HOME PHONE
CELL PHONE
MEMBERSHIP CATEGORY (select one)
Member ($99)
Life ($30)
Associate ($80)
Associate Life ($30)
Affiliate ($50)
Student ($20)
Two-year member ($178)
You may make a tax-deductible contribution to the Minnesota
Speech-Language-Hearing Foundation. If paying your dues by check,
simply add your donation amount to your total payment. If paying your
dues by credit card, please write a check to the Foundation for your
donation amount.
Contributions or gifts to MSHA are not deductible as
charitable contributions for federal income tax purposes. Dues
to MSHA are not deductible as a charitable contribution, but may be
deductible as an ordinary & necessary business expense. A portion of
the dues, however, is not deductible as an ordinary & necessary
business expense to the extent that MSHA engages in lobbying. The
non-deductible portion of dues for 2015 is 52%. We suggest you
consult your tax advisor for specifics.
CODE OF ETHICS:
By submitting this application, I agree to abide by the MSHA Code
of Ethics.
PAYMENT
$
Check
Foundation donation
$
Incentive discount
$
VISA
MasterCard
Total amount enclosed
$
Membership dues
NAME ON CARD
(payable to MSHA)
CARD NUMBER
AUTHORIZED SIGNATURE
EXP DATE
VERIFICATION CODE