OHCA Application

Business Partner Membership

Company Name:	*	Company Tax ID#
Contact First Name:	*	Contact Last Name:	*
Contact Title:	*
Company Address:	*	Company City:	*
Company State:	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming *	Company Zip Code:	*
Phone Number:	*	Fax Number:
800 Phone Number:
Email:	*	Website:
Please enter information below if there are ADDITIONAL contacts for your business that you'd like included in your OHCA membership records other than the primary contact listed above.
Billing Representative		Copy Contact Information from above
Contact First Name:		Contact Last Name:
Contact Title:
Address:		City:
State:	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	Zip Code:
Phone Number:		Fax Number:
Cell Phone Number:		Email:
Marketing Representative		Copy Contact Information from above
Contact First Name:		Contact Last Name:
Contact Title:
Address:		City:
State:	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming	Zip Code:
Phone Number:		Fax Number:
Cell Phone Number:		Email:

Please list a brief description of your company's product/services. (100 characters or less)	*
Choose the Category that you would like to have your company listed under in the OHCA directory:	Accounting/BillingAdvertising/MarketingArchitectural /Landscaping ServicesAttorney/LegalComputer/Technology SolutionsConsulting - ClinicalConsulting - Dining ServicesConsulting - EducationConsulting - OtherDrug TestingDurable Medical EquipmentEducationFinancial ServicesFlooringFood ServicesFuneral ServicesFurniture/TextilesGroup PurchasingHospiceHousekeeping/LaundryHuman ResourcesInsurance - GeneralInsurance - Risk ManagementJanitorial / MaintenanceLiftsMedical/Surgical SuppliesOnline EducationOtherHealth Services and ProductsPharmaceutical CompaniesPharmacy ServicesPrinters/PublishersPromotional/Office ProductsReal EstateReferral ServicesRehab/Therapy ServicesSafety/Security ServicesSkin and Wound CareStaffing/RecruitmentTelecommunications/Phone ServicesTransportation SalesTransportation/AmbulanceInsurance - Workers CompX-Ray / Lab Services *

Payment Information
Membership Dues Annual Association Dues:	$350.00
Voluntary OHCA PAC Dues:	$50.00
Total Amount of Dues:	*