FULL INDIVIDUAL MEMBERSHIP APPLICATION - Home - NACHC



4509135-111760FOR NACHC USE ONLY:Batch #_____________________IS#________________________00FOR NACHC USE ONLY:Batch #_____________________IS#________________________51435309245FULL INDIVIDUAL MEMBERSHIP APPLICATION00FULL INDIVIDUAL MEMBERSHIP APPLICATION7501 Wisconsin Avenue, Suite 1100W ? Bethesda, MD 20814 ? 301.347.0400 ? 301.347.0459Please print or type the requested information below_______________________________________________________________________________[First Name] [Last Name] ________________________________________________________________________________[Title] _______________________________________________________________________________[Mailing Address] _______________________________________________________________________________[City] [County] [State] [Zip]_______________________________________________________________________________[Telephone] [Fax] [E-Mail](Enhanced) Full Individual Membership ($65.00)BENEFITS:Participate in Social Media Community specifically for the Health CentersReceive an Annual subscription to the Community Health Forum magazineEligible to participate on NACHC committees/task forces (Must also belong to an Organization that is a member of NACHC in good standing)Invitation to attend the new “Insider Teleforum” to hear from leaders in the movement and receive policy & advocacy updatesReceive special policy and Advocacy Newsletter providing strategic updates and key insights from quest authorsEligible to receive 20% discount on ATSU online courses offered by the College of Graduate Studies (Must also belong to an Organization that is a member of NACHC in good standing)Receive a free annual National Health Center Week Advocate CalendarORGANIZATIONAL AFFILIATION:[Name]____________________________________________________________________________[Address] _______________________/________________________________/___________/_____________[City] [County] [State] [Zip]______________________/__________________________/_______________________________[Telephone] [Fax] [E-Mail]Is this organization a member of NACHC?Yes, Member ID # __________________ NoUncertainWhat is the nature of your affiliation?Present: Past: StaffBoardVendor/ConsultantOther5143510287000StaffBoardVendor/ConsultantOtherDUES PAYMENT METHOD:Payment is enclosed in the amount of $ _____________________Please charge the credit card number listed below in the amount of: __________________□ American Express□ Diners Club□ MasterCard□ VisaCard Number: _________________________________________________________Expiration Date: _______________________________________________________Name on Card: ________________________________________________________Authorizing Signature___________________________________Date______________ ................
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