Massachusetts Health Council, Inc. -- Membership Application

To become a member of the Massachusetts Health Council ...

Complete the form below.

Print the page.

Attach your check made payable to "MA Health Council"

Mail your application and payment to:

Massachusetts Health Council, Inc.
73 Oak Street - 1st Floor
Newton, MA 02464-1438

Amount due is on a sliding scale.
Please submit the appropriate amount for your organization.

Dues Schedule

Annual Revenue

Dues Amount

Under $100,000

$100

$100,000 - $300,000

$300

$300,000 - $750,000

$600

$750,000 - $1.5 Million

$750

Over $1.5 Million

$1,000

Name of Organization

Address of Organization

City, State, Zip

Telephone Number

Fax Number

E-mail Address
(very important for timely updates)

Web Address

Executive Director

President/CEO

If information for individual requesting membership is different from above, list the differences below:

Name

Title

Address

Telephone Number

Fax Number

Name of Applicant

Date

© Copyright 2003-2008 Massachusetts Health Council, Inc. All rights reserved.
MA Health Council, Inc. • 73 Oak Street - 1st Floor • Newton, MA 02464 • (617) 965-3711
Massachusetts Health Council is a non-profit, tax exempt organization.

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