Monthly Membership/Renewal

LAACADIANA AHU (LAFAYETTE)

LAACADIANA dues: $25.00 / 12 = $2.08
LASW dues: $80.00 / 12 = $6.67
NAHU dues: $195.00 / 12 = $16.25
Total dues: $25.00 per month

Member ID
If you know your member ID, enter it here and you may leave all other fields blank unless you wish to make any changes. Please enter an e-mail address if you wish to receive a receipt via e-mail.

Personal Information
Prefix		None Dr. Hon. Mr. Ms. Mrs. Rev.
First Name
Middle Name
Last Name
Suffix		None II III IV Jr. Sr.
Designation(s) (separated by commas)
Informal Name
Website
Company
Practice Areas		Long Term Care Individual Plans TPA Disability Large Group Self Insured Managed Care Small Group Medicare Supplement Retirement RX-PBM Dental Worksite Mktg
Name of Local HU Assoc.
Referred by (If applicable)
Work Information
Address 1
Address 2
City
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Zip/Postal Code
Phone
Fax
E-mail		Please note: your membership confirmation will be sent to this address. This email will serve as your login to Manage My Membership - access to NAHU's online database.
Home Information
Address 1
Address 2
City
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Zip/Postal Code
Phone
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Payment Information
Dues Amount		$25.00
Monthly Payment by		Visa   MasterCard   AmEx/Optima   Discover
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Exp. Date
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Montly Payment by		Bank Draft
Routing Number
Account Number