KPHRA APPLICATION FOR ADMISSION & MEMBERSHIP

(Print Form, Complete, and Mail to Address Below)

Kentucky Public Human Resources Association Certification Program

Name:__________________________________________________
Position:________________________________________________
Employer:_______________________________________________
Business Address:_________________________________________________
City: _______________________________________________

State: ____________

Zip____________________

Business Phone ( ) _______________________________ Business FAX ( ) _______________________

Home Address:__________________________________________________
City :________________________________________________

State: __________

Zip:____________________

Home Phone: ( ) ____________________________

Agency Website____________________________________
E-Mail: __________________________________________

Application For: (Mark all that apply)

________ Individual Membership ($50.00)


________ Agency Membership ($100.00 - Designate 2 voting members)*


________ Certification (Registration fee: $25.00; covers 5 year statute of limitations)


________ Recertification (Registration fee: $25.00; covers 2 year statute of limitations)


________ TOTAL Enclosed (make checks payable to "KPHRA")


Calendar year in which certification/recertification program is expected to begin _______________ .**

o A check for appropriate amount is attached.

o I understand that I must acquire, read, and follow the Guidelines and Procedures for the certification program.

o Please send me a copy of the program Guidelines and Procedures.


SIGNATURE _____________________________________________ DATE _____________________

Send or give application to: Janet Van Nevel, KPHRA Treasurer, c/o Kentucky Institute of Public Governance and Civic Engagement, 113 McCreary Hall, 521 Lancaster Ave., Richmond, KY 40475-3102

* Agency members may send up to 4 people to meetings at the membership rates.

** Experience credit may be earned beginning January 1 of the first year in which educational credit is earned.