Independent Clinics Access Membership Application

Independent Clinics Program Access Membership Application

Please fill out the application below or download the application here, fill it out, and return it to bobbie.orchard@wha1.org.

Independent Clinics Program Access Membership Application

Company or Practice Information

Company/Practice Name *

DBA (if different)

Physical Address *

Mailing Address *

City *

State *

Zip Code *

Phone *

Website

Number of Locations *

Current FTEs

GPO

Fee

Main Contact Information

Name

First

Last

Title *

Phone *

Secondary Phone

Email Address *

Secondary Email Address

Secondary Contact Information

Name

First

Last

Title *

Phone *

Secondary Phone

Email Address *

Secondary Email Address

Authorized Signature

Signature

I acknowledge that by typing my name below, I am signing this application electronically.

Signature

Please contact bobbie.orchard@wha1.org if you prefer to sign via PDF or hard copy application.

Name

First

Last

Title

Date

If you are human, leave this field blank.

By Partner:

By Service:

By Name:

Independent Clinics Program Access Membership Application

Please fill out the application below or download the application here, fill it out, and return it to bobbie.orchard@wha1.org.

Company or Practice Information

Main Contact Information

Secondary Contact Information

Authorized Signature

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