MD-SHRM Membership Application

Name: ______________________________________________

Title: _______________________________________________

Organization: _________________________________________

Address: ____________________________________________

___________________________________________________

Area Code/Phone Number: _____________________________

Area Code/Fax Number: _______________________________

E-mail Address: ______________________________________

Description of Risk Management responsibilities in present position:

Are you a member of the American Society for Healthcare Risk Management?

___ No ___ Yes

Recruited by: _______________________________________________

To join MD-SHRM, please print a copy of the above membership application and send it with a check in the amount of $50.00 or $25.00 (made payable to MD-SHRM) to:

Betty Norman, BSN, MBA, CPHRM
Risk Management Consultant
Glatfelter Insurance Group
9322 Waltham Woods Road
Baltimore, MD 21234
410-668-0047
bnorman@glatfelters.com