LIACS Membership Application
First Name:
Last Name:
Title
Street Address
City
State
Zip
Home/Cell Tel. No
Email
Hospital / Company
Work Tel
Work Fax
New Applicant or Renewal?
New Applicant
Renewal
Please Select
Referred to LIACS By:
Are you currently an IAHCSMM Member?
Yes
No
Please Select
Qualifications:
CRCST
CIS
CHL
FCS
Please choose your FREE membership:
Active Member (i.e. Hospital Employee)
Associate Member (i.e. Vendor)
Please Select