CapitalHealthCare Membership Application
   Organization Information
 
   Primary Contact Information (Please list additional contacts on back of application)
 
   Membership Type
 
   Payment Method
 

   Please list any other organizational contacts that would like to receive communications about council events
   and activities
 
 
 
 
 
 
 
 
 
 
 
Organization Name
Address
City
State
Zip Code
Phone
Fax
Email
Contact Name
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Please select the one that best describes your organization
Membership dues cover October 1 through September 30 of any given year. Those joining after October will be
charged for a full year membership. The balance will be credited toward the next membership year dues. Your
payment is tax deductable as payment to a local unit of government under PA-7. A receipt will be provided upon
request. Tax Number/EIN 38-2481244.
(Payable To: Capital Healthcare and Employment Council)
(Mail To: Capital Healthcare and Employment Council, 2110 South Cedar Street, MI)
Contact Name 1
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Contact Name 2
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Contact Name 3
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Contact Name 4
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Contact Name 5
Address
City
State
Zip Code
Phone
Fax
Email
Contact Title
Enter security code: