National Rural Health Association

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Improving the Health of 62 Million Rural Americans

Membership Form

Please fill out the following form. Required fields appear in red.

Personal Contact Information

I would like to:

Apply for a new membership
Renew an existing membership

Name

Title

Organization Name

Address

City

State

Zip Code

Phone

Fax

E-mail Address

Membership Level

Please select your membership level:

Organization - with 25 or fewer employees ($660)
Organization - with 26 to 100 employees ($1200)
Organization - with more than 100 employees ($1980)
Individual ($225)
Rural Health Clinic ($325)
Supporting ($3500)
Student ($10)

Contacts

Please fill out information for up to 8 contacts.

Please insert my personal contact information from above.

Name

Title

E-mail

Phone

Fax

Address

City

State

Zip Code

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Contact 2

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Contact 3

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Contact 4

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Contact 5

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Contact 6

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Contact 8

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Student Information

Name of University

Name of Program

Field of Study

Date of Graduation

How did you hear about the NRHA?

Friend/Colleague
NRHA Literature
NRHA Publication
Web Search
NRHA Conference
State Rural Health Association
Media/News
Other

Are you a member of your state association?

Yes
No

Please select your preferred method of payment.

Credit Card
Invoice Me

Click here to download a printable application to mail or fax.

Please contact Sharon Hutinett, member services coordinator, at 816-756-3140 x.17 or shutinett@NRHArural.org with questions.

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National Rural Health Association

Rural Health Topics

Rural Health Fact

Upcoming Events

May 18

May 19-21

June 16-18

July 21-23

September 28-29

September 29 - October 1

December 1-3

Membership Form