EmailMeForm
2017 Membership Dues Renewal & Assessment
Complete this form to renew your network's membership from May 1, 2017 through April 30, 2018.
2017 dues assessment form should be completed by April 1, 2017 and 2017 dues must be paid by April 15, 2017.
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 electronic invoice for 2017 dues at the email address listed above. (Note - the electronic invoice will be from laura.sturgeon@drane-cpas.com)
I have assessed my 2017 dues and will mail the check to NCHN, 400 S. Main Street, Hardinsburg, KY 40143 (Note - please check to be sure the NCHN mailing address is up to date within your payment system).
I have assessed my 2017 dues and will pay with credit card via PayPal. I understand there is a $35 processing fee for using this method.
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 2017. 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-Based Organizations
Community Health Centers
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
Physician Owned Clinics
Post-Secondary Educational Institutions
Public Health Departments
Rural Health Clinics
Schools/School Districts
Small Hospitlas (25-50 beds)
Surgical Center
Other *
Total # of Members
*Please specify here, if you entered "other" above.
How can NCHN best support your network needs this year?
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