Join HAES - New Members

MEMBERSHIP APPLICATION

PLEASE FILL THE FORM BELOW TO JOIN US AND MAKE A DIFFERENCE!

* Required

CONTACT INFORMATION

Prefix

First Name

Middle Name or Initial

Last Name

Suffix

Birthdate

(Optional)

Address Type

Address Line 1

Address Line 2

City

State

Zip Code

Country

Email Address

Email Location

Primary Phone Number

Type

Secondary Phone Number

Type

CAREER STATUS (Multiple selections possible)

Employed Full Time

Employed Part Time

Self Employed

Seeking Employment

Student Intern

Retired

Latest Position

Employer

Previous Position

Previous Employer

EDUCATION

Latest Degree / Year

Educational Institution

Previous Degree / Year

Previous Educational Institution

MEMBERSHIP

Membership Type Desired

Check here if licensed

License Number

How would you like to participate as a member? (Multiple selections possible)

Leadership

Recruitment

Project Mgt.

STEM Education

Fundraising

Event Mgt.

Marketing

I.T.

APPLICATION SUBMITTAL

Create Password

Confirm Password

By checking the Acknowledgement box below you certify that you have provided truthful information in this application for membership, you agree to the Terms and Conditions of becoming a member of the Haitian-American Association of Engineers and Scientists, and if accepted as a member you will abide by the By-Laws and Code of Ethics of the organization.

Acknowledgement

Data Record Successfully

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