Calendar Year: ______________________________
Name: _________________________________________________________________
Job Title (if professional): __________________________________________________
Organization: ___________________________________________________________
Business Street Address: __________________________________________________
Business City, State, ZIP: __________________________________________________
Campus Address (if UHM): ________________________________________________
Home Street Address: _____________________________________________________
Home City, State, ZIP: _____________________________________________________
If needed, where would you like your HERA mail sent? __ Home __ Business
Phones: Business: ______________ Home: _______________ Fax: ________________
E-mail Address: __________________________________________________________
Dues: __ Professional $15 __ Full-time Student $10
Purchase Orders are welcome. For more information call Kathleen Berg 956-4952 or Truc Nguyen 956-6507.
Please make check payable to HERA and send this form and check to