Georgia Local Section
                 APPLICATION FOR LOCAL SECTION MEMBERSHIP

Name (please print) ______________________________ Title _____________________________

Business affiliation:_________________________________________________________________

Mailing Address: _________________________    Telephone:______________________________

__________________________________________    Fax:	______________________________

__________________________________________    E-Mail:	______________________________

Is this your home _____ or Work _____ Address?

Consultant? Yes:____ No:____

Employer Catagory: (Check one only)
____ Government				____ Student
____ Commercial / Industrial		____ Vendor
____ Education				____ Other __________________________________
____ Self Employed 

Are you a National AIHA member?    ______ Yes   _____ No
(If not, you can call 703-849-8888 to obtain an application)

Date: _________________________________           Signature:

Local Section Dues: Full $20, Associate $20, Emeritus (retired) no charge
(Circle membership category you are applying for -- see bylaws)

To complete your application, please enclose your check, payable to the Georgia
Local Section, AIHA and mail to:

	Kristen Butler
	GTRI
	430 Tenth St. NW, North Bldg.
	Atlanta, Ga. 30332-0837

	Phone:  404-407-6643
	hilarie.schubert@gtri.gatech.edu