Virginia Chapter of HIMSS
Membership Application

Chapter Membership is offered on a calendar year basis. Please complete the following information
and return it to the address below:

Name: _______________________________

Title: ________________________________

Company: ________________________________

Address: ________________________________

City: _____________ State: ________ Zip Code: _____________

Phone #: (________) _________________

Fax #: (________) _________________

e-mail: _____________________________

HIMSS Status (check one):
q Member q Sr. Member
q Fellow q Not an HIMSS Member

Primary Focus (check one):
q Management Engineering q Administration
q Information Systems q Clinical Systems
q Telecommunications q Finance
q Other ____________________________

Membership dues (check one):

_____ Regular Member ($30)

_____ Student Member ($15)

(Meeting Fees: $15 per Member, $30 per non-Member)

List Topics of Interest or Recommended Speakers:
__________________________________
__________________________________

Send completed application with check or money order, payable to Virginia Chapter of HIMSS to:

Cathy Stam, VA HIMSS Treasurer
c/o SMS
51 Valley Stream Parkway
Malvern, PA 19355 (Mail Code E8A)