Hampton Roads SHRM SHRM Primary Chapter Designation

Chapter #: 102 Chapter Name: Hampton Roads SHRM

I hereby designate the above named chapter as my primary chapter for SHRM membership coding purposes. I understand that: 1. This in no way precludes membership in other chapters.2. This allows SHRM to list my membership to this chapter for financial support program purposes only.

(You must be a current national member of the Society for Human Resource Management to complete this form.)

Please type or neatly print the following information.

Date: _____________________

Name: _____________________________________________________________________________

SHRM Member ID#: ______________________________

Company Name: _____________________________________________________________________

Address: ___________________________________________________________________________

City: ______________________________________________ State: _______ Zip: _______________

Phone: ________________________ Fax: ________________________

Email: ______________________________________________________________________________

Member’s Signature: ___________________________________________

Thank you!

Please submit this completed form to:

HRSHRM #0102Attn: Brian Winterstein, Vice President of Membership638 Independence Parkway, #240Chesapeake, VA 23320

Fax: 757-842-4839Email: sayres@hrshrm.org