HMA Chapter Application

We the undersigned, as duly elected representatives of the _________________________________

Chapter of HMA, do hereby apply for chapter membership with HMA. In applying for chapter status we affirm the goals and

purposes of the HMA and our chapter's commitment to these.

President/Chair: Signature:_______________________________________________________

Date: _____________________________ Name: ______________________________________

Address:_______________________________________________________________________

Phone: Day: ______________________Evening: ______________________________

Fax: ______________________ Email:______________________________________

Secretary: Signature: ____________________________________________________________

Date: _____________________________Name: ______________________________________

Address: ______________________________________________________________________

Phone: Day: _______________________ Evening: _____________________________

Fax: _______________________ Email: _____________________________________

Select one:

___ The Chapter President/Chair shall act as the chapter email contact.
___ The Chapter Secretary shall act as the chapter email contact.
___ Someone other than the President/Chair or Secretary shall act as the chapter email contact.

Please include all contact information for this person on the reverse of this form.

Geographic area to be represented by this chapter: ________________________________________
(Area must be defined by geographic area and US Postal Service 3-Digit Zip Code Prefix Codes)

NATIONAL HMA MEMBERSHIP IS REQUIRED OF ALL CHAPTER MEMBERS

HMA Chapter Roster

New Chapter Information:
Letter to Prospective Chapters
Guidelines for New Chapters
HMA Chapter Application
HMA National Chapter Bylaws

Chapter Annual Report Forms:
Financial Report Forms
Officer Roster Report Form
Chapter Activity Report
3 Digit Zip Code Prefix Area Designation Instructions

Annual Chapter Reports:
Report Instructions
Financial Report
Officer Roster Report
Chapter Activity Report
Annual Report Extension Form

To Chapter Contacts