Please complete and submit the application to become an MHN Affiliate. Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20212022202320242025 Organization Name * Contact Person * Title * Email * Phone * Fax * Address 1 * Address 2 * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Chose the options that best describe your organization / company: * International National State Local Hospital/clinic/physician office Health Association Fraternal organization Government entity (federal/state/local) Religious organization Activist organization Other (please describe) Chose the options that best describe your organization / company: Other (please describe) Is your organization health related? * Yes No Is the applicant a division or chapter of a broader organization? If so, please explain the relationship to the broader organization. * Describe the purpose and goals of the applicant. * When was the applicant founded? * Is the applicant a membership organization? * Yes No If so, who is eligible to be a member? Describe the population your programs serve. * How is the applicant registered with the Internal Revenue Service (if applicable)? * 501(c)(3) 501(c)(4) 501(c)(6) Other (please describe) How is the applicant registered with the Internal Revenue Service (if applicable)? Other (please describe)
