Membership Application

General Information

*** denotes fields that are not displayed on web site.

* denotes required fields.

Organization Name:		*** Contact First Name:
		*** Contact Last Name:
		*** Contact Title:
	For display on web site		Mailing Address (NOT displayed on web site)
Address:		*** Address:
City:		*** City:
State:		*** State:
ZipCode:		*** ZipCode:
	Use the above address for Mailing Address

Map:		Contact Email:
Phone Number:		Contact Phone Number:
Extension:		Extension:
Fax Number:		Cell Phone:
Email Address:		Pager:

Clinic URL:
*** Notes:
Year Incorporated:	please use four digit format

Login Information (not displayed on the web site)

Login (please use an email address):
Password:
Retype Password:

Services

Medical:	Yes No
Dental:	Yes No
Pharmacy:	Yes No
Lab:	Yes No
MentalHealth:	Yes No
Xray:	Yes No
Other:	Yes No
Other Description:
	Check to set all Yes, Uncheck to set all No

Hours

Monday:	Yes No
MondayOpen:
MondayClose:
Tuesday:	Yes No
TuesdayOpen:
TuesdayClose:
Wednesday:	Yes No
WednesdayOpen:
WednesdayClose:
Thursday:	Yes No
ThursdayOpen:
ThursdayClose:
Friday:	Yes No
FridayOpen:
FridayClose:
Saturday:	Yes No
SaturdayOpen:
SaturdayClose:
Sunday:	Yes No
SundayOpen:
SundayClose:

Other Information

Donations:	Yes No
Require Fee:	Yes No
Map:
See All Ages:	Yes No
Limitations:	Yes No
Limitations Description:
Specific Geographic Area:	Yes No
Geographic Area List:

Insurance Information

Bill Insurance:	Yes No
Insurance Govt List:

Operations Information

# Patient Visits:
# Unduplicated:
# Total Volunteers:
# Physicians:
# Dentists:
# Pharmacists:
# RN/LPN:
# Therapists:
# Volunteer Hours: