| Date: |
______________________________________________ |
| Name: |
______________________________________________ |
| Address: |
______________________________________________ |
| City: |
______________________________________________ |
| State: |
______________________ |
Zip: __________________ |
| Day Phone: |
(
) __________________________ |
| Evening Phone: |
(
) __________________________ |
| E-mail: |
______________________________________________ |
| Birth date: |
______________________________________________ |
| Social Security# |
______________________________________________ |
| Employer: |
______________________________________________
(person, stable, business)
|
| Employer Address: |
______________________________________________ |
| City, State, Zip: |
______________________________________________ |
| Present Position: |
______________________________________________ |
| Beneficiary: |
______________________________________________
(Professional members only) |
| Relationship to Beneficiary: |
______________________________________________ |
| |
|
| If accepted, I agree to abide by all
the regulations and By-Laws governing the PHA. |
| Signature: |
______________________________________________ |
| For Professional Membership Only |
______________________________________________
______________________________________________
(signature of 2 LIPHA Professional Members needed) |
Carol Little - 57 Locust Ave., Farmingville, NY 11738, Ph 631-732- 0235 Fax- call first to send