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*

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

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

Submit

* Required

Leading Healthcare

Membership Application

MHA Membership Application

Submitter Information

Organization Information

Primary Contact Information

Chief Executive Officer Information

Member Hospital Endorser

Leading Michigan to Better Health

Membership Application

MHA Membership Application

Submitter Information

Organization Information

Primary Contact Information

Chief Executive Officer Information

Member Hospital Endorser

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