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Associate Business Membership Application

Required information is marked by an asterisk (*)

Incorrectly filled out fields will be highlighted in red

Business Name: *

Address:

City, State Zip:

Phone:

Fax:

E-mail: *

Website:

Contact Person: *

Contact Person Title:

Contact Person E-mail: *

Address (if different from mailing address):

City, State Zip:

Please provide a description of your business (please limit description to no more than 50 words):*

Please select a vendor type from the drop down menu:

Applicant Name:

Applicant Title:

Payment must accompany application. Please select your preferred payment method below. You may pay by check or credit card. If paying by credit card you must contact WHCA with your credit card information at (800) 562-6170. Membership will not be valid until payment is received.

WHCA Associate Business membership fees are as follows…

If you join anytime between January 1 and June 30: $400 for the year.

If you join anytime between July 1 and December 31: $200 for the year.

WHCA membership is valid January 1—December 31, renewal invoices are sent in October/November of each year, and those who renew or join on or before December 31st of each year will be listed in the directory for the following year.

We would like to pay via credit card:
Please call the WHCA office at (800) 562-6170 to supply your credit card information

We are sending a check

Areas of Interest: Please check the areas where you are most interested:

Assisted Living Activities

Newsletter Advertising

Leadership Opportunities

Nursing Home Activities

Website Advertising

Quality Assurance

Trade Show Opportunities

Event Scholarships

Political Action

Chapter Meetings

Guest Speaker

Education & Training

Other:

In consideration of services provided by WHCA, signing of this application constitutes your agreement to abide by the articles and bylaws of WHCA as now in existence or hereafter amended. Dues, in accordance with the attached fee schedule, are payable upon submission of this application and annually thereafter on January 1 of each succeeding year, and do not cease until WHCA receives written notification of termination.

*You are applying for membership with Washington Health Care Association. By checking this box, you agree to pay membership dues and note that cancellation must be made in writing thirty days prior to cancellation effective date.