Rural Health Clinic-Constituency Section Registration

□ Yes, our Rural Health Clinic would like to become a member of the Rural Health Clinic-     Constituency Section of the Nebraska Rural Health Association!

□$150.00 for the first RHC

□$50.00 for each additional RHC

□We currently have a NeRHA organizational (i.e. hospital) membership, please add a RHC to this membership for $50.00 each

Name of organization/hospital: _________________________________

RHC: _____________________________________________________________

Contact Person: ______________________________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Phone: ____________________________________________________________

E-mail: ____________________________________________________________

Total Amount Enclosed: ______________________

RHC: ______________________RHC: ________________________

Contact Person: _______________Contact Person: _________________

Address: ____________________Address: ______________________

City, State, Zip: _______________City, State, Zip: _________________

Phone: _____________________Phone: _______________________

E-mail: _____________________E-mail: _______________________

RHC: ______________________

Contact Person: _______________ Please make checks payable to:

Address: ____________________Nebraska Rural Health Association

City, State, Zip: _______________ 2222 Stone Creek Loop South

Phone: _____________________ Lincoln, NE 68512

E-mail: _____________________

Nebraska Rural Health Association

If you are registering more then one Rural Health Clinic please provide information for each Clinic below!