Massachusetts Health Council Renewal Application

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Massachusetts Health Council, Mass Health Council, MA Health Council, MHC

Membership Renewal Application for Organizations

The Massachusetts Health Council is a council of organizations. If you are retired or a provider that is not affiliated with a qualified organizational member, you may be able to join as an individual. Please call Betty at the MHC office (617-965-3711) to inquire about individual membership.

INSTRUCTIONS
To renew your membership with the Massachusetts Health Council ...

Complete the form below.

Hit the "Submit" button.

Follow the instructions for payment of renewal fee.

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

Organization Dues Schedule
July 1, 2011 to June 30, 2012

Annual Revenue

Dues Amount

Under $100,000

$120

$100,000 - $300,000

$360

$300,000 - $750,000

$720

$750,000 - $1 Million

$1,000

$1,000,001 - $1.5 Million

$1,200

$1,500,001 - $5 Million

$1,500

Over $5 Million

$1,800

Name of Organization
REQUIRED

Address of Organization

City, State, Zip

Telephone Number

Fax Number

E-mail Address
REQUIRED
(very important for timely updates)

Web Address

Executive Director

President/CEO

Other contact person
(please add title)

Method of payment

Check Credit Card

The Massachusetts Health Council is a non-profit, non-partisan statewide organization on wellness programs, obesity prevention,
school nutrition programs, healthcare reform, healthcare cost, healthcare programs, health promotion, and health status indicators.
MA Health Council authors the annual "Common Health for the Commonweath: Massachusetts Trends in the Determinants of Health."

© Copyright 2003-2011 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.