EmailMeForm
2016 Membership Dues Renewal & Assessment
Complete this form to renew your network's membership from May 1, 2016 through April 30, 2017.
2016 dues assessment should be completed and RETURNED BY May 31, 2016.
Network/Organization Name:
*
Most recent fiscal year operating expenses (the total operating expenses reported on your 990 or other tax form):
*
Enter the TOTAL AMOUNT ($) of the network’s most recently reported Operating Expenses, as reported on the network’s 990 form and/or other Internal Revenue Service reporting format, including expenditures for all programs & services, including programs supported by grant funds, and any additional companies that are under the management of the parent organization. NCHN Membership dues are based on your reported operating expenses. Dues are as follows:
Less than $250,000 = $575
$250, 001 - $500,000 = $875
over $500,001 = $1,150
Network Leader's Name:
*
Job Title:
Mailing Address:
City:
State:
Zip Code:
Email
*
Organization's Website Address:
Payment Method:
*
I would like to receive an invoice for 2016 Membership Dues at the address listed above.
I have assessed my 2016 dues and will mail the check to NCHN, 400 S. Main Street, Hardinsburg, KY 40143
Official Contact
NCHN is an organizational membership organization. The network organization is the member of NCHN; however, a contact person for each network must be designated each year to be the official contact for NCHN membership information. Please indicate in the box above, the name of the network’s official representative for 2016. This is the person of record that will receive official NCHN notifications, updates, and other information throughout the year. Please note that the network leader serves as the NCHN official contact for the majority of our members; however, another full-time staff member can be designated the contact by the network leader if desired.
Your Information (Optional, but appreciated)
We constantly strive to maintain up to date information on our member networks. This information is utilized to assist committees to understand your needs and to assist collaboration among members. We know that your membership composition and programs change periodically. Please take a moment to complete the information below, so we can keep our membership records up to date.
Network Programs and Services
Member Composition (please enter the # of each member type)
Ambulance Providers
Behavioral Health Providers
Community Health Centers
Community-Based Organizations
Critical Access Hospitals (CAH's)
Free Clinics
Hospice Agencies
Hospital-Owned Provider Clinics
Large Hospitals (>200 beds)
Long Term Care Facilities
Medium Hospitals
Oral Health Providers
Other [please list name(s)]
Physician Owned Clinics
Post-Secondary Educational Institutions
Public Health Departments
Rural Health Clinics
Schools/School Districts
Small Hospitlas (25-50 beds)
Total # of Members
How can NCHN best support your network needs this year?
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