Group Membership Application Survey

1.Organization Information(Required.)

Name

Street Address

City

State

Zip

Phone Number

Fax Number

2.I am signing up as a:(Required.)

Health Care Provider-Based Group

Solution Provider Group (Standard)

Solution Provider Group (Premium)

3.Group Lead

Does not need to be a SHSMD member. This person acts as the group's administrator, handling logistics like payments and approving who should be on their roster.(Required.)

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

4.Executive Sponsor

Must be a SHSMD member. This person is the group's SHSMD champion. They receive our quarterly newsletters and act as the point person to ensure their group is aware of benefits and updates. They will also be responsible for letting SHSMD know about the group’s needs and what would be helpful.

AHA Member ID

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

5.Please attach your Member Roster list in .PDF, .DOC or .DOCX format and include the following (separate) fields for each member:(Required.)

First Name; Last Name; Title; Organization; Street Address; City; State; Zip Code; Phone Number; Email

No file chosen