AHHA Associate Membership Application

AHHA Associate Membership Application

Date

Company/Organization Name*

Organization Address (Street, City, State, Zip)*

Company/Organization Website*

Contact Name*

Contact Email*

Associate Membership Type*

Please select which level of membership you are applying for

Select or enter value

Company/Organization Background*

Please provide a brief history of your organization, its services or product lines, and mission.

AHHA Members*

Do you currently work with any AHHA member facilities? If so, please list them below. You can find a full membership list on our site.

Target Audience*

Which of the following would be the target audience for your service, product, or alliance (mark all that apply)

Select

Other

If you selected "other" in target audience, please provide more detail.

Partnership Value*

Why would a hospital, nursing home, or healthcare entity want to do business or partner with you? Why are you interested in partnering with AHHA?

Conflict of Interest

Please identify (if any) conflict of interest that might exist

Send me a copy of my responses