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Membership Application

Personal Information

First Name: *
Last Name: *
Job Title:
Member Type: *
Password: *  
(Minimum of 8 characters long)
Confirm Password: *
(Case Sensitive)
Preferred District: *
Professional Designation:
Mailing List: PIHRA sometimes sells our mailing list to HR product & service companies. If you do not wish to receive these mailings please check this box.
Include in Directory Search:

If "Include in Directory Search" is checked, then the following four Preferred Directory fields are required.

Preferred Directory Address:  
Preferred Directory Phone:  
Preferred Directory Fax:  
Preferred Directory Email:  

Home Address Information

Address 1:
Address 2:
City:
State:
Zip:
Phone: (xxx)xxx-xxxx
How Did you Hear About PIHRA? *
I was Referred to PIHRA by:

Business Address Information

Company:
Address1:
Address2:
Address3:
City:
State:
Zip:
Phone: Ext.
(xxx)xxx-xxxx
Date Employed From: mm/yyyy
Date Employed To: mm/yyyy
Are you a SHRM Member?
SHRM Member Number:

Preferred Correspondence: Where would you like your PIHRA mail to be sent? *


HR Functions Performed:
Please check at least one. *











Other:

Previous Human Resources Experience

Company:
Job Title:
Employed From:

mm/yyyy 		 to 
mm/yyyy
Exempt:

Company:
Job Title:
Employed From:

mm/yyyy 		 to 
mm/yyyy
Exempt:

Company:
Job Title:
Employed From:

mm/yyyy 		 to 
mm/yyyy
Exempt:

Demographic Information (Optional)

Gender:
Education:
Company Revenue: (in millions)
Years In HR:
Company Size:
Race/Ethnic Identification:
Business & Industry Code:

Fax/Email Permission Form

To comply with FCC "Unsolicited" Fax Rules and in response to the deletion of the "established business relationship" clause from the Telephone Consumer Protection Act (TCPA) we are asking our current and potential members to sign this Fax and Email Permission Form. By signing, you are acknowledging that Professionals in Human Resources Association (PIHRA) can send you facsimiles and Email including Membership Renewals, Invoices, Registration and Program Information. Please contact the Membership department at 800-734-5410 or membership@pihra.org with any questions.

If authorization box is checked, these fields are required.

Fax #1 (Primary):  
Fax #2:
Email #1 (Primary):    
Email #2:  
Authorization:
By Checking this box, you are authorizing fax and email permission from Professionals In Human Resources Association (PIHRA).
Date: 5/12/2008

Please acknowledge consent by signing below
Name:  
Company:
Signature:  
(Typing your name is your electronic signature.)

PIHRA Marketing Information Request

PIHRA offers a number of great opportunities to form a relationship with our members. Website, print, e-blast advertising as well as exhibiting opportunities at PIHRA events, and much more!
Please send me information about PIHRA advertising and sponsorship opportunities.