Not a member of NAHU? Join today to receive HIU every
month plus the other benefits of NAHU membership.
NAHU Membership Application
Yes! I want to join NAHU and receive all the benefits of membership. My information is below.
I’d like to learn more about NAHU membership. Please contact me about chapters in my area.
I’m not interested in joining NAHU, but I’d like to continue receiving HIU. Here’s my $40
payment for a year’s subscription.
First Name
Last Name
Designation
Company
Title
Referral/Sponsor
Mailing Street Address
City
State
ZIP
Work Telephone
Work Fax
Work E-Mail Address
Home Telephone
Home Fax
Home E-Mail Address
Home Street Address (for legislative purposes)
City
State
Zip
Local Association (see the following page)
Form of Payment Enclosed:
____________________________
Monthly Draft (please select one)
Check (payable to NAHU)
Annual Credit Card (please select one)
Amount:
Bankdraft
Credit Card Draft
Visa MasterCard
Am Ex Discover
Bankdraft/Credit Card Draft Authorization Form:
I (we) hereby authorize NAHU to initiate debt entries to my (our) account as indicated.
Monthly debits will equal one-twelfth of any current applicable national, state or local dues.
(Please include a voided check from the account to be drafted, or write credit card number below.)
Name (as it appears on the check or credit card)
Signature
Account Number
Expiration Date
Please Mark the Box or Boxes for the Areas of Your Practice:
Long-Term Care Disability Managed Care Retirement
Individual Large Group Small Group Worksite Mktg.
TPA Self-Insured Medicare Supplement Dental
Mail to: NAHU • 2000 North 14th Street, Suite 450 • Arlington, VA 22201 • Fax to: 703-841-7795
If you have questions, please contact Illana Maze at 703-276-3810
