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Who We Are

Our members are organizational representatives from community and tribal based providers of comprehensive primary health care, and organizations who support the work and share the vision of the Association.


 


Please complete the application below and click the submit button:

Indicate the category of membership:
Organizational ($500/yr)   Associate (250/yr) 

Representative Name:
Organization Name:
Physical address:
City:
State: Zip:
Mailing Address:
If different
City
State: Zip:
Area Code:
Phone: Ext:   Fax:
Email:
URL (website):

Type of Organization or Agency:  (Please check all that apply)

501(c)3 non-profit corporation
Tribal Health Center
Private Practice (Group)
Unit of Higher Education

Other (please describe.......
Federally Qualified Community Health Center (FQHC)
FQHC "look alike"
Community-based social service organization
Community-based health service organization
Unit of State or local government

Why you are interested in becoming a member of the Association:

What are your expectations of the Association relative to your organization:

Thank you!  Please click the submit button (or clear to re-enter the form).  You will receive a confirmation that the application has been submitted.  If you do not receive a confirmation, please call 775 887-0417 X 106 or email Dalene Altamirano.

 
         
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