Associate Membership Application

Date of Application *

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Name (first and last) *
Title (if any)
Organization
Street Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone Number *

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Fax Number

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Email *
Type of Membership *
 Individual 
 Organization 
Please check the phrase that best describes the nature of your role as a NCHN Associate Member *
 Former Network Leader of NCHN member organization 
 Former staff member of NCHN member organization 
 Area health education center 
 State rural health association 
 State office of rural health 
 Similar national healthcare organization 
 Individual representing any other local, state, or national organization that supports NCHN's mission 
 Other (please indicate below) 
If you selected "Other" please enter your role:
Please check your primary interest in becoming a NCHN Associate Member (check all that apply) *
 Access to NCHN services as outlined in the Associate Membership Brochure  
 Access to networking opportunities with health networks  
 Pursuit of partnership activities with NCHN to support health networks 
 Engage in and have opportunity to contribute expertise and resources to NCHN and NCHN Members  
 Other (please specify below) 
*If you selected "Other" please specify your primary interest in NCHN:
Please provide brief statement regarding your desire to become an Associate Member and how your membership supports the NCHN mission. *
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