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
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
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 - OtherDurable Medical EquipmentEducationFinancial ServicesFood ServicesFuneral ServicesFurniture/TextilesGroup PurchasingHospiceHuman Resources/StaffingInsurance - GeneralJanitorial ServicesLiftsReimbursement/Billing ServicesMedical/Surgical SuppliesOffice Products/Office MachinesOtherPharmacy ServicesPrinters/PublishersPromotional ProductsReal EstateReferral ServicesRehab/Therapy ServicesSafety/Emergency ProductsStaffingTelecommunications/Phone ServicesTransportation/AmbulanceSkin and Wound CareX-Ray ServicesConsulting - ClinicalConsulting - DietaryConsulting - EducationDrug TestingHousekeeping/LaundryInsurance - Risk ManagementPersonal Care ProductsTransportation SalesDrug TestingWorkers Comp *

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