Membership Application

Submittor Information

Organization Information

Primary Contact Information

Chief Executive Officer Information

Member Hospital Endorser

(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.