HCA Associate Membership Admission 2016 HCA presents your “Admission to HCA Membership 2016!” We’ve simplified the process for you to preserve your membership this year electronically. Simply complete the form below with your contact information. Then select the appropriate dues category based on your agency’s total revenue. If you have any questions about this process, contact Laura Constable at (518) 810-0660 or lconstable@hcanys.org. Question Title * 1. Agency Information Main Contact: * Company: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title * 2. DUES CALCULATIONAssociate Members may be asked to validate their Annual Budget response below by providing supporting documentation. $3,500 - Associate Member Organization with Annual Budget over $200,000 $1,500 - Associate Member Organization with Annual Budget under $200,000 Question Title * 3. Dues Payment Information Please invoice me. Please contact me for credit card information. Question Title * 4. Terms and ConditionsBy checking this box I acknowledge that this membership renewal application and associated dues are for the membership year that runs from January 1, 2016 through December 31, 2016. I also verify that the information contained herein is true and correct, and that the applicant meets the eligibility requirements for the membership category for which it has applied. Agree Done