AzRHA MEMBERSHIP FORM
Please print out and return with fee to the address below:
Arizona Rural Health Association, Inc.
2066 W. Apache Trail, Suite 116
Apache Junction, AZ 85220
Phone number: 1-800-390-8004
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| Name________________________________________ |
| Home Address_________________________________ |
| City___________________________ |
| State_____________________ |
| Zip Code__________________ |
| Phone_________________________ |
| Employer_____________________________________ |
| Employer Address______________________________ |
| Phone_________________________ |
| For AzRHA, Inc. mailing, please use: |
| Home Address |
| Work Address |
Profession____________________________
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E-mail_________________________________________
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| Signature______________________________________ |
Date_________ / ___________ / ___________
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Annual Membership Dues
Individual $25.00
Organizational $100.00
Student $10.00
Please return this form and membership fee to:
AzRHA, Inc.
2066 W. Apache Trail, Suite 116
Apache Junction, AZ 85220
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