NSSLHA Chapter Recertification

Please complete this form by December 31st of the current year to become recertified for the next. NSSLHA/ASHA numbers are not required. The form may be submitted with advisor's and officers' names only. In addition to completing this form, please e-mail a copy of your chapter bylaws to nsslha@asha.org.

A chapter will remain in good standing with the National Office if the chapter retains an advisor who is a current member of ASHA and the local chapter officers maintain current membership in National NSSLHA. Failure to comply with these requirements will place your chapter in an inactive status.

Chapter Information

Chapter Category (Required)

Graduate students only

Undergraduate students only

Combined (both Graduate and Undergraduate)

Other (e.g., distance learning, SLPA)

How many students are enrolled in the audiology and/or speech program at your college or university? (Required)

How many students are local members of your NSSLHA chapter? (Required)

How many students in your local chapter have national membership in NSSLHA? (Required)

What month/year does this chapter hold officer elections (MM/YY)? (Required)

What is/was the date of the first membership meeting in the fall semester (MM/DD/YY)? (Required)

What is/was the date of the first membership meeting in the spring semester (MM/DD/YY)? (Required)

How often do you host local chapter meetings? (Required)

Chapter Name (Required)

Chapter Address (Required)

Office Telephone Number (Required)

Office Fax Number

E-mail Address

Web Site Address

Chapter Advisor

Name

ASHA Membership #

E-mail address

Co-Advisor

Name

ASHA Membership #

E-mail address

Chapter President

Name

NSSLHA Membership #

E-mail address

Term

Chapter Vice President

Name

NSSLHA Membership #

E-mail address

Term

Other Officer

Name

NSSLHA Membership #

E-mail address

Term

Other Officer

Name

NSSLHA Membership #

E-mail address

Term

Other Information

If the chapter has officers representing SLP/SLS and A/HS/Deaf, please list information for both officers. Use this space below, if necessary, to list all officers.

Additional Information

	Please send a list of our National NSSLHA Members.
	This chapter has tax-exempt certification.
	This chapter is inactive. Please remove us from the active list.

Required fields must be completed to submit the form.

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