Freestanding licensed hospitals located in Arizona and Arizona hospital-based healthcare systems are eligible to become Hospital Members of AzHHA.
Section I

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* 1. Name of organization

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* 2. Owned by

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* 3. Operated by

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* 4. Street address

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* 5. Mailing address (if different from street address)

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* 6. City, state, zip code

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* 7. Main line phone number

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* 8. Organization's website

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* 9. Name of chief executive officer/principal

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* 10. Title of chief executive officer/principal

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* 11. Chief executive officer / principal direct phone number

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* 12. Chief executive officer/principal email address

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* 13. Name of Accounts Payable contact

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* 14. Email address of Accounts Payable contact

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* 15. Organization's Social Media

Section II

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* 16. Type of Organization (Check all that apply.)

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* 17. Type(s) of care provided (Check all that apply.)

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* 18. If applicant is comprised of more than one hospital facility, please list all hospitals within the health system.

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* 19. Briefly describe your hospital or health system, such as geographic area served, distinct populations served, or other unique aspect.

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* 20. How did you hear about us?

Section III - All applications for healthcare membership must be reviewed by AzHHA’s president and chief executive officer. AzHHA may, at the sole discretion of its Board of Directors, grant or deny any application for membership and may censure, suspend or expel any member, in conformance with AzHHA’s bylaws.

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* 21. Electronically sign this application by typing in the full name of the person submitting this application.

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* 22. Title of person submitting this application

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* 23. Date

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