Membership Application Associate Members Awards Advancing Safe Care Award Advancing Safe Care Award Nomination Form Healthcare Leadership Award Healthcare Leadership Nomination Form Ludwig Community Benefit Award Ludwig Community Benefit Nomination Form Meritorious Service Award Speak up Award Special Recognition Award Board of Trustees Careers at the MHA Current Opportunities Committees Councils Member Benefits Associate Membership Bylaws Data Reporting Services Membership Application Physician Membership Physician Membership Application Our Hospitals Michigan Hospitals By Health System Public Health Partnerships Vaccinations Staff Directory MHA Membership Application To apply for membership, please complete all questionsSubmitter InformationType of Membership(Required)Type I Hospitals & Health ProvidersType II Affiliate MembersType III Associate MemberType IV Allied Members (Personal)Type V Auxilians & Honorary MembersName(Required) First Last Title(Required) Email Address(Required) Phone(Required)FaxAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Organization InformationName(Required) Phone(Required)FaxAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Organization Type(Required)Financial ServicesHealth IT & Data ServicesHealthcare Consulting & Support ServiceInsurance CompanyLegal ServicesMedical Groups & StaffingMedical Equipment & TestingOtherIf selected “Other”, please provide type of service Ownership Type(Required)For-ProfitNot-For-ProfitNumber of Employees(Required)Less than 10More than 10Primary Contact InformationName(Required) First Last Title(Required) Email Address(Required) Phone(Required)FaxAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Chief Executive Officer InformationChief Executive Officer Name First Last Title Email Address PhoneFaxPurpose for Joining MHA(Required)Related Memberships Service DescriptionOpt-In to MHA communications/Hold CEO RoleYesNoMember Hospital EndorserHospital CEO/Senior Level Executive Date MM slash DD slash YYYY (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 MM slash DD slash YYYY Email Address Note: Forms will not be accepted if they include URLs.CommentsThis field is for validation purposes and should be left unchanged.
