NeRHA Membership Application

Name __________________________________________________________________

Organization ____________________________________________________________

Address_________________________________________________________________

City/State/Zip____________________________________________________________

Phone__________________________________________________________________

Fax____________________________________________________________________

Email___________________________________________________________________

Membership Classification

O New     O Renewal

O $25 Student

O $35 Consumer / Community Member

O $50 Individual / Healthcare Professional

O $150 Rural Health Clinics / Constituency Section

             ($150 for the first RHC, $50 each additional)

O $250 Organizational (Less than $4 million operating budget)

O $500 Organizational (Over $4 million operating budget)

**Please note:  If you have an organizational membership,                  

             RHCs will be $50 each

Committee Interest

O Membership  O Education  O Finance 

O Legislative O Community Relations

Please mail application with payment to:

NeRHA

2222 Stone Creek Loop South

Lincoln, NE 68512