Business Associate Member Application - Kansas Health Care Association

Business Name:*

Address:

Street Address City State ZIP Code

Phone:

Fax:

Email:*

Website:

Contact Person:*

Contact Person Title:

Contact Person Email:*

Address: (if different from above)

Street Address City State ZIP Code

Please provide a description of your business:

(please limit description to no more than 50 words)

Vendor Type:*

Applicant Name:

Applicant Title:

Payment must accompany application. Please select your preferred payment method below. You may pay by check or credit card. If paying by credit card you must contact KHCA/KCAL with your credit card information at ((785) 267-6003. Membership will not be valid until payment is received.

KHCA/KCAL Sales Associate Membership fee is $450 per year.

KHCA/KCAL membership is valid January 1—December 31, renewal invoices are sent in October/November of each year.

Payment:*

We would like to pay via credit card

We are sending a check

If paying by credit card, please call the KHCA/KCAL office at (785) 267-6003 to supply your credit card information.

Areas of Interest: Please check the areas where you are most interested:

Areas of Interest: Other

In consideration of services provided by KHCA, signing of this application constitutes your agreement to abide by the articles and bylaws of KHCA as now in existence or hereafter amended. Dues, in accordance with the attached fee schedule, are payable upon submission of this application and annually thereafter on January 1 of each succeeding year, and do not cease until KHCA receives written notification of termination.

You are applying for membership with Kansas Health Care Association. By checking this box, you agree to pay membership dues and note that cancellation must be made in writing thirty days prior to cancellation effective date.*

I agree