Chief Products/Services:        

Present Job Title:                  

Area/Function of HR Field:       Choose One HR Generalist Employment/Recruitment Benefits Compensation Labor/Industrial Relations Training/Development Health/Safety/Security EEO/Affirmative Action Research Education Other (please specify)
                                             Other:

Years of Experience in HR 

Years at Present Position      

*Employer Address           

*City                               

*State                             

*Zip                                

*Phone                            

 Fax                             

*E-Mail                            

*Brief Description of Present Duties and Responsibilities:

Prior Employment History

Company/Position Held/Length Of Service

1.

2.

3.

Personal Information
(Home address, phone and e-mail will not be published.)

*Home Address        

*City                    

*State                 

*Zip                     

*Phone                 

*E-Mail                 

URL                     

Education:

 High School:     Degree:

       College:     Degree:

         Other:     Degree:

Are you a National SHRM Member?                    Yes No

If yes, what is your SHRM membership number?  

When did you join SHRM?                               

Please check the certifications you attained

PHR           CCP
SPHR         CBP
GHPR            Date of Certification:

Please indicate any areas in which you would be willing to assist our chapter: