Membership Form General Membership Application Thank you for your interest in ADIHA. Please complete this application to join. Should you encounter any challenges, please contact us at main@adiha.org. Fields with a red asterisk are required. Account Infomation End Section Username Email Address First Name Last Name Password PERSONAL INFORMATION Select Type of Membership * Professional Student Retired Affiliate Prefix First Name * Last Name * Date of Birth Preferred Mailing Address * Home Address Business Address HOME ADDRESS Street Address/P.O. Box * Apt. No. City * State/Province * Zip/Postal Code * Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Telephone * Email Address * BUSINESS ADDRESS Street Address/P.O. Box * Apt. No. City * State/Province * Zip/Postal Code * Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Telephone * Email Address * Continue EDUCATION Name of College/University Degree Bachelor's Master's Ph.D. Major Field of Study Date/Expected Date of Completion Name of College/University Degree Bachelor's Master's Ph.D. Major Field of Study Date/Expected Date of Completion Name of College/University Degree Bachelor's Master's Ph.D. Major Field of Study Date/Expected Date of Completion Name of College/University Degree Bachelor's Master's Ph.D. Major Field of Study Date/Expected Date of Completion Continue Professional Registration AICP EIT PE RA RLS Other Specify Other Technical Certification COMMITTEE MEMBERSHIP We encourage all members to join at least one Standing or Ad Hoc committee. After completing this membership application, please go to the membership page and complete the Standing CommitteParticipation Form. Your ADIHA membership includes a required membership in at least one of the Project Interest Groups. Each of the Project Interest Groups will engage in one or more of the following activities, including, but not limited to: examine current conditions in Haiti and the Diaspora, research and develop new practices with a strong focus on sustainability and economic development, collaborate with various relevant research and professional entities in Haiti and abroad, develop a close working research relationship with other Haitian organizations and institutions, provide technical support to organizations working for the development of Haiti and its Diaspora, develop policies and professional guidelines, develop and publish technical materials, organize seminars and conferences as well as professional and educational activities, develop training and license guidelines as well as educational materials. Select Project Interest Group(s) * Architecture Agriculture and Agro-Industry Chemical Engineering Computers Construction Industry Disaster Planning & Management Economic Development Education Energy Entrepreneurship Environment & Water Resources Geotech Housing Government & Policy Math Mechanical Engineering Planning and Urban Design Scientific Research Sciences Structures Sustainability Technology and Innovation Telecommunications Transportation Systems Other Specify Other * PROFESSIONAL INFORMATION Employer Name * Type of business with which you are currently employed * Academic Consulting Contractor Corporation Developer Government Manufacturer Military Non-Profit Research Supplier Testing Laboratory Utilities Other Specify Other * Primary role in business * Chairman of the Board/President/CEO Owner/Principal/Partner General Manager Vice President Chief Engineer/Director Department Head/Senior Manager Engineer/Architect Computer Scientist Project Manager Educator Scientist/Researcher Retired Other Specify Other * Please provide a brief job description * Continue ADDITIONAL INFORMATION Do you have any of the following social networking accounts: Facebook, Twitter, LinkedIn or other networks? If yes, provide information. How did you hear about ADIHA? * Are you renewing your membership? If so, please write down your member number and chapter affiliation: Do you belong to other professional organizations? If yes, please list them. DEMOGRAPHIC Gender Female Male Haitian Ancestry Yes No Country of Citizenship Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe CERTIFICATION I hereby apply for ADIHA membership, and I certify that the information I have provided above and any supplemental information that I may provide in support of this application is true and correct. If my membership application is accepted, I agree to abide by the ADIHA governing documents. Certification * I Agree reCAPTCHA