HRA Mail-In Memebership Form

Please print out this form and mail it with your payment to: HR Association, P.M.O. #134, 10645 North Tatum Blvd., Suite 200, Phoenix AZ 85028-3053 Phone:800-685-2811 Fax:(240) 363-6117 Email:hra@holographic.org
This is a new application for New Student Member Cost: $75 per year (Note: All memberships are renewable annually) Today's Date:__________________________________
I have enclosed $75 for my dues I wish to donate $________ for HR Scholarship Fund (Optional) Total: $_______
Method of payment:	Check or Money Order	Visa
	Master Card	American Express
Account Number: ___________________________
Expiration Date: ____________________________
Signature: _________________________________
Please give us your name and current mailing address:
Name: ____________________________________
Street Address: _____________________________
City, State, Zip: _____________________________
Phone: ( )_______________________________
Fax: ( )_________________________________
E-Mail: ____________________________________