SHRM Primary Chapter Designation

 Lake/Geauga Area Chapter                 Area 03                 Chapter #0172

NOTE:  You must be a current National Member of the Society for Human Resource Management to complete this form.  For National SHRM Membership information, visit www.shrm.org or contact any of the LGA SHRM Board Members. 

Completing this designation allows SHRM to list my membership to this chapter for statistical reporting and financial support program purposes only.

I hereby designate the Lake/Geauga Area Chapter, Area 03, Chapter #0172, as my primary chapter for SHRM membership coding purposes.  I understand that this in no way precludes membership in other chapters.

Name: _____________________________________ Title: _______________________

SHRM Member ID#:  ______________________  SHRM Membership Expires:______________ 

___     Company Name __________________________________________________________

Address ________________________________________________________________

City/State/Zip ____________________________________________________________

Email Address ___________________________________________________________

Work Phone ______________________  Fax __________________________________

 ___     Home Address ___________________________________________________________

City/State/Zip ____________________________________________________________

Email Address ___________________________________________________________

Phone ________________________________

**Please place a check mark next to the address we should use for Chapter correspondence.

Date __________  Member’s Signature __________________________________

                                                                                            (Required to validate)     

Return original to:     LGA SHRM Membership

                                    P.O. Box 5125

                                    Mentor, OH  44061-5125

To expedite, you may fax a signed copy to:  440-954-3232, attention LGASHRM.  Please note, this form is also available online at www.lgashrm.org.

NOTE: National SHRM Members are considered “guests” at LGA SHRM events, unless an LGA SHRM Chapter Designation has been assigned.