Date:

Name:

Address:

Phone:

Email address:

Date of birth:

Have you been a member of GPC-AHDI previously?

Are you a member of AHDI?

What is your AHDI membership number?

Are you a CMT, RMT, RHIT, or RHIA?

What is your ID number?

Would you be interested in volunteering on any committee?

Send form:

Deborah Purse, CMT

160 Ulysses Street

Pittsburgh, PA 15211

Make check out to GPC-AHDI

Fee:   $12.00 Practicing (member of AHDI)

           $15.00 Associate (not a member of AHDI)

           $5.00 Student (must provide proof)

CMT/RMT STUDY GROUP

I, _______________________, would like to participate in the Greater Pittsburgh Chapter-AHDI study group so I may obtain my CMT/RMT. 


Please fill in the following information.

Date of test:

How often do you plan or wish to participate in the group?

Do you mind doing this via email, web site or face to face?

Signed:________________________________  Date:____________
Address:
Phone number:
email:

If you have not signed up to take your test or paid AHDI yet, do you need further information about how to go about this contact me at debpurse@comcast.net and I will be glad to send on the information to you.