TENNESSEE ASSOCIATION OF CARDIOVASCULAR & PULMONARY REHABILITATION MEMBERSHIP APPLICATION/RENEWAL In order for TACVPR to process your application, it must be completed with factual information.  This membership fee is entitles you all the TACVPR member services until the Fall conference 2007.  Continued membership requires a renewal by November 14, 2006. A $10 late fee will be added after this date.  The fee is not prorated during the year. Please print the following information: Name:  ____________________________  Date:_______________________     Professional Designation:______________________  Work Title__________________ Name of your institution: __________________________________________________ Name of your program: ___________________________________________________ Home Address: _______________________ _______________________ Work Address: ______________________________    ______________________________                    Home Phone:  ________________________ Work Phone:  _____________________ Preferred Mailing Address:        Home Address        Work Address     (please circle one) E-Mail Address: _______________________  Fax #: ___________________________  Membership:                New                Renewal    (please circle one)   (If renewing, what year did you become member: _____________)         Student         yes           no        (please circle one) If yes, list institution:____________________________________________ Membership Dues:   $ 30.00 - (Yearly)      $ 10.00    (Late Fee)      $ 15.00 - (Student) (Yearly) Please Indicate Amount Paid: _____________________ Please mail application & check/money order, payable to TACVPR, to the following address: Margie Brewer INTERxVENT Programs Memorial Health Care System 2525 deSales Ave Chattanooga, TN 37404