Membership Application

MHA Membership Application

To apply for membership, please complete all questions

Submitter Information

Type of Membership*

Name*

Title*

Email Address*

Phone*

Fax

Street Address*

City*

State*

ZIP*

Organization Information

Name*

Website Address*

Phone*

Fax

Street Address*

City*

State*

ZIP*

Organization Type*

If selected “Other”, please provide type of service

Ownership Type*

Number of Employees*

Primary Contact Information

Name*

Title*

Email Address*

Phone*

Fax

Street Address*

City*

State*

Zip*

Chief Executive Officer Information

Name

Title

Email Address

Phone

Fax

Purpose for Joining MHA

Related Memberships

Service Description

Opt-In to MHA communications/Hold CEO Role

Member Hospital Endorser

Hospital

CEO/Senior Level Executive

Date

(To be signed by the Chief Executive Officer or his/her designee)
I certify on behalf of my organization that I have read the bylaws of the MHA and agree to support the purpose and objectives of the MHA. I understand that this application, upon being filed, will be referred to the MHA Executive Committee for consideration. I also understand that before becoming a member, we must remit the dues as specified.

Full Name

Title

Signature Date

Email Address

What are the Michigan Health & Hospital Association’s initials (three letters)? *

Submit

* Required

Membership Application

MHA Membership Application

Submitter Information

Organization Information

Primary Contact Information

Chief Executive Officer Information

Member Hospital Endorser

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