Philadelphia & Suburban Healthcare

                                                         Human Resources Association
Text Box: MEMBERSHIP APPLICATION Text Box: Directions: This portion of the Application must be returned.

TYPE OF MEMBERSHIP

Please check the type of membership to which you are applying.

First:      ___________________________________________

Last:      ___________________________________________

Title:     ___________________________________________

Facility: __________________________________________

Address: __________________________________________

Address2 __________________________________________

City: ___________________________

ST: _____

Zip: _________

Email:  __________________________________________________
Text Box: Email: Joseph.Micucci@mail.tju.edu Phone: 215 952-9992 FAX: 215 952-9014 Text Box: PASHHRA FEES Text Box: SEND APPLICATION AND FEE TO PASHHRA Joe Micucci Director of Human Resources Methodist Hospital Division, TJUH 2301 South Broad Street Philadelphia, PA 19148

APPLICATION

Phone: ______________________

Fax: __________________