Last Name   First Name   Middle Initial
Title 
Employer
Employers Address 
City    State   Zip Code
Phone  -- Fax  -- Cell Phone  --

Home Address 
City    State   Zip Code
Home Phone  --     E-Mail
Address where mailings should be sent (Select One) Home Work

Referred to CSHE by:

Briefly Describe Your Present Duties

Number of years in current position

Number of employees under your supervision

List areas of special interest/expertise relative to facilities
management, health facilities and/or environmental issues.

Are you an ASHE Member
(American Society for Healthcare Engineers)           
(Select One) Yes No

Chapter
(Select One) Central Coastal Central Valley Inland Kings River Kern River Los Angeles Northeastern Orange County Redwood San Diego San Francisco South Bay Counties

Membership Type
(Select One) Affiliate ($150/year) Facility ($50/year) Student ($20/year) Retired ($25/year)

Payment Method
(Select One) Credit Card