Michigan Industrial Hygiene Society
Print-Friendly Offline Membership Renewal Form

This form is for those paying with a check. Please print the completed form for your records and mail a photocopy with you remittance. Please make any updates to your information as required.

*What is your E-mail address? *Required
Enter your contact information below:
*First Name,
Middle Initial, *Last Name:
IH Designation:
 (CIH,CSP, etc. - Please limit to your primary)

My contact and other information remains the same.

IF REQUIRED, please make any changes in the form fields below (do not check above).
Title:
Company:
Address:
 Work Home   
Address 2:
City/State/Zip:
Phone:
   Work Home 
Fax Number:
Additional Information:
Comments:
Membership Level:
*Type of Membership:
  Honorary (send form, dues are waived)
Life (send form, dues are waived)

The following information is optional - select only if changes have occurred:

Which of the following certifications do you hold? (check all that apply)

CIH CSP CHMM
IHT OHST PE
Other: (please list - do not include 40 hr. training classes)

Which related organizations are you a member of?

WMIHS ASSE SOT OPA (DRS)
ACGIH APCA APHA AOHN (NURSES)
Other: (please list)

Which of the following committees do you have an interest in?

Awards International Newsletter 
Community Outreach Legislative Nominating 
Continuing Education Membership Publicity
Program and Arrangements    

Payment Options:

Upon submittal MIHS will receive your application electronically by email. We will confirm your membership upon receipt of your remittance and printed application.

Please press the Send button only once. It may take a few moments to process.

MIHS promises not to use this information in any manner inconsistent with the purpose intended. We will require your E-mail address to contact you with assistance.

Checks by Mail - Please print and forward completed form with remittance to:

MIHS
46410 Continental Drive
Chesterfield, MI 48047