Membership Application - MHA | Michigan Health & Hospital Association

URL

This field is for validation purposes and should be left unchanged.

To apply for MHA membership, please complete all questions

Submitter Information

Type of Membership(Required)

Name(Required)

First Last

Title(Required)

Email Address(Required)

Phone(Required)

Fax

Address(Required)

Street Address City State Zip

Organization Information

Name(Required)

Phone(Required)

Fax

Address(Required)

Street Address City State Zip

Organization Type(Required)

If selected “Other”, please provide type of service

Ownership Type(Required)

Number of Employees(Required)

Primary Contact Information

Name(Required)

First Last

Title(Required)

Email Address(Required)

Phone(Required)

Fax

Address(Required)

Street Address City State Zip

Chief Executive Officer Information

Chief Executive Officer Name

First Last

Title

Email Address

Phone

Fax

Purpose for Joining MHA(Required)

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

First Last

Title

Signature Date

Email Address

Note: Forms will not be accepted if they include URLs.