Holographic Repatterning Association
Mail-In Practitioner Membership Application

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 Level 1 or Certified Membership Application for Accredited HR Practitioners

Please Check One of the Following:
Level I
Certified

Cost: $125 per year (Note: All memberships are renewable in January)

Today's Date:__________________________________

I have enclosed $125 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: ____________________________________