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Member Number:

Date:

Name:

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Phone:     Fax:

Home Address:

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Home Phone:

E-Mail Address:

Education: High School Some College Associate Degree Bachelor's Degree Some College beyond Bachelor's Master Degree MBA Doctorate

Certification: (i.e. SPHR, CMC, PHR, etc.):

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Type of Organization: Communications Construction Consulting Education Financial Health Care Manufacturing Government Retail/Wholesale Transportation Utilities Other

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Years of Experience in Human Resources:

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