Associate Membership Application Any individual or organization that supports NCHN’s mission will be considered for associate membership. Eligible categories include: • Former Network Leaders of NCHN member organization; • Former staff member of NCHN member organization; • Area health education centers; • State rural health associations; • State offices of rural health; • Similar not-for-profit national healthcare organizations; • Individuals representing any not-for-profit local, state or national organization that supports NCHN’s mission. Note: All applications for Associate Membership must be approved by the NCHN Board of Directors. Please allow at least two (2) weeks for processing.
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 *	### - ### - ####
Fax Number	### - ### - ####
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. *