member app Word
Tri-State SHRM
Your central HR connection to
Training, Resources & Innovation in the Tri-State Area
P.O. Box 1485
Uniontown, PA 15401
Contact: Bobbi Ryan – VP of Membership
724.439.7884
bobbi.ryan@sensus.com
Membership Application
Please print all information – Thank you!
Contact Information
1. Name AND Title: _____________________________________________________________
2. Company Name:_____________________________________________________________
3. Company Address:___________________________________________________________
4. Company City/State/Zip:_______________________________________________________
5. Business Phone:_____________________________________________________________
6. Business Email Address:______________________________________________________
7. Home Address:______________________________________________________________
8. Home City/State/Zip:__________________________________________________________
9. Home Phone:_______________________________________________________________
10. Home Email Address:_________________________________________________________
11. Email address for chapter communication....................................... c Business c Home
12. Address to be used for mail and membership directory listing........ c Business c Home
13. Check this box only if you DO NOT want to be listed in the Membership Directory............... c
Professional Information
14. My current SHRM membership number is: ________________________________________
NOTE: You MUST be a member of SHRM to be considered for membership in Tri-State SHRM. If you are NOT currently a SHRM member, you can register on-line at www.shrm.org OR you can complete the attached Member Madness form and enclose it with this form; PLEASE make a separate check payable to “SHRM” for your SHRM dues. Thank you.
15. I learned about Tri-State SHRM through: __________________________________________
16. I would describe my role as:
c HR Practitioner c Consultant/Service Provider c Educator
Other (please explain/describe):_______________________________________________
17. Company Size (number of Ees).. c Less than 25 c 25-50 c 51-99 c 100-500 c > 500
18. HR Department Size......................... c Less than 5 c 5-9 c 10-24 c 25-49 c > 50
19. Years in HR............................................ c Less than 3 c 3-5 c 6-9 c 10-15 c 15+
20. Certification............ c SPHR c PHR c Other: _____________________________
21. Education.............. c High School c Some College c BA/BS c Master’s c Ph.D.
Major OR Area of Specialization: ______________________________________________
_________________________________________________________________________
22. I am a CURRENT member of the following professional associations:
__________________________________________________________________________
__________________________________________________________________________
23. I have attached a current resume................................................................... c Yes c No
Chapter Involvement Information
24. The reason(s) that I am interested in becoming a member of Tri-State SHRM:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
25. I am interested in serving on the following committees:
c Certification: Organizes and oversees HRCI national certification training (i.e., PHR, SPHR).
c Community Outreach: Organizes and oversees projects that enhance HR’s role in the community.
c Conference: Organizes and oversees activities relating to annual conferences; may include developing alliances with sister chapters.
c Finance: Assists in Chapter accounting and financial activities; committee chair is Treasurer.
c Legislative Affairs: Works with national SHRM to keep chapter members abreast of current legislative and regulatory developments.
c Membership: Responsible for recruitment, new member orientation and membership communication; committee chair is Vice President of Membership.
c Marketing/Public Relations: Promotes chapter awareness in the community.
c Nancy J. Watts Memorial Scholarship: Coordinates fundraising and recipient selection of annual scholarship.
c Newsletter: Oversees all activities related to publication of monthly newsletter; committee chair is Secretary.
c Program: Schedules and directs chapter programs, training, round table discussions and special events; committee chair is President-Elect.
c Research Projects: Coordinates research projects to determine area HR trends and best practices.
c Student Chapter Affairs: Develops and serves as liaison with affiliated student chapters.
26. I would be willing to chair the following committee:
__________________________________________________________________________
27. I would like to be considered for the following Board position:
__________________________________________________________________________
28. I would be interested in presenting a workshop or conducting a round table discussion on the following topic(s): ___________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Payment Information
29. I am a member of SHRM and have designated Tri-State SHRM as my Primary Chapter Affiliation and am enclosing a copy of the completed on-line form................................... ANNUAL DUES: $0.00
NOTE: This form can be found at http://moss07.shrm.org/Communities/VolunteerResources/ResourcesforChapte.... Tri-State SHRM’s chapter number is 663.
OR
I am a member of SHRM, but have designated another chapter as my Primary Chapter Affiliation and enclosed a check for my annual dues................................................................... ANNUAL DUES: $25.00
Applications cannot be processed without signature and payment (if applicable).
Signature:_____________________________________________________________________
Name (printed):_________________________________________________________________
Date:_____/_____/_____
Chapter Use Only:
Date Received: ________/________/________ Date Approved: ________/________/________
Authorized Signature: ___________________________________________________________________________
