Associated Membership

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I, HEREBY APPLY, on behalf of the hereinafter named business, for Associate Business membership in the Independent Nursing Home Association. I understand that as an Associate member of Innovative Health Alliance, I am entitled to all the privilege (with the exception of voting) of the Association.

The following information being supplied to you is accurate to the best of my knowledge and belief.

Name of Business*
Type of Business*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax*
Email*
Contact Person*
First Last
With what other business in the State of MS are you involved, either through common ownership, common management, or otherwise?*
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If you have questions, please call our office at 601-325-3298 or e-mail your questions to ashley.inha@gmail.com

Associated Membership

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