Membership Application

*Required field
Personal Information
*First Name:
*Last Name:
Credentials:
*Home Street Address:
*City:
*State:
*Zip:
Phone:
Cell:
*E-Mail:
May we publish your name and address in our Membership Directory?	Yes No

Business Information
Employer:
Street Address:
City:
State:
Zip:
Phone:
Fax:
May we publish your employer information in our Membership Directory?	Yes No
List other professional organizations to which you belong
Employment Setting:	Hospital Vendor Insurance Co/Other Payers Other
Category:	Auditor UR/QA Case Manager Other

COMMITTEE PREFERENCE: (Rate in the order of preference with #1 being the most preferred)
Education	Legislation	Nominations
Standards & Bylaws	Certification	Newsletter
Program	Marketing	Finance

Membership Information
To ensure full access to all the features of our website and to receive periodic email notifications of significant AAMAS events please complete the following.
*Type of Membership:	New Member Renewal
	All Renewing members will use their same previous username and password. If for any reason, you still need to be assigned one please email us at admin@aamas.org to request a new username and password.
*Username: (at least 4 characters long)
*Password: (at least 5 characters long)
*Confirm Password:
*Screen Name: (Please use your full first and last name)
*Email Address
*Preferred Mailing Address	Home Work

Payment Information
MEMBERSHIP FEE IS $100.00
*Name as it appears on Credit Card:
Billing Address	Same as Personal Address Same as Business Address Different Address
*Street Address:
*City:
*State:
*Zip:
*Credit Card Type:
*Credit Card # (16 digits):
*CVV (MasterCard, Visa, and Discover has 3 digit CVV on the back of the card. American Express has a 4 digit code on the front.):
*Exp Month:
*Exp Year: