Any organization doing business in Arizona, including not-for-profit, investor-owned, and government-operated entities, that provides direct patient care services to people, provides health insurance or coverage, or offers consumer support to the healthcare community as a substantial part of its activities is eligible to become a healthcare member.
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. Describe the organization’s purpose and nature of services provided

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* 17. How did you hear about us?

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* 18. What do you hope to gain from membership?

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

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* 20. Title of person submitting this application

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* 21. Email of person submitting this application

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* 22. Phone number (direct) of person submitting this application

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* 23. Date

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