This form is for membership RENEWAL ONLY Step 1: Complete information form below & click CONTINUE at bottom Step 2: Complete payment on following screens You will receive a membership card via United States Postal Service surface mail.
FIRST NAME:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP:	(use 5 digits only)
COUNTY:
WORK PHONE:	000-000-0000
HOME PHONE:	000-000-0000
EMAIL:
Official communication is sent via eMail. You will receive MSHA eMail only if you subscribe on the MSHA Home page. Official notices are also posted in MSHA News on the MSHA web.
NAME ON CHARGE CARD:
MS DEPT OF EDUCATION LICENSE:	None SLP A SLP/A
MS DEPT OF HEALTH LICENSE:	None SLP A SLP/A
Current ASHA member ?	No Yes
ASHA Certification	None SLP A SLP/A
Highest degree	CLICK TO SELECT Master Doctorate Education Specialist Bachelor
Primary Work Setting	SELECT SETTING Public School Healthcare Private Practice University Faculty/Staff Student Retired
I hereby apply for membership renewal  in the Mississippi Speech-Language-Hearing Association. I agree to abide by the Bylaws of the Association.	Yes No 5% of dues is utilized to defray lobbying expenses and is not tax deductible