NRHA Rural Hospital Partnership Application

NRHA Rural Hospital Partnership Application

Managed by NRHA Services Corporation
IMPORTANT: PLEASE READ BEFORE PROCEEDING

By completing and submitting this application for the NRHA Rural Hospital Partnership Program, you’re expressing your interest in joining us. We encourage you to submit the application if:
- You have reviewed all partnership details and requirements.
- You are prepared to discuss the partnership contract upon approval.
- You are genuinely interested in exploring a partnership with NRHA.
By checking this box, I confirm that I have read and understand the above statement.
Name of person completing the application*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Organization Details
Organization*
Website URL*
Year founded*
Legal Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of person to sign the contract (Ultimate Decision Maker)*

First NameLast Name
Title*
Email*
example@example.com
Name of selected rural health expert to represent your organization? (This person must have a baseline familiarity with rural hospital buying cycles, culture, and ability to speak the unique healthcare language)*

First NameLast Name
Rural Hospital and Clinic Experience*
Title*
Email*
example@example.com
Are you currently developing or have developed educational content focused on RURAL HEALTHCARE?*

YesNo
If yes, please upload your most recent collateral or presentation here.

Browse Files

Cancelof
Short description of services and solutions the company offers *
How many rural facilities is the company currently working with now?*

0-56-15more than 16we are not in any rural facilities yet
Which one best describes the company?*

publicly tradedprivately owned
What is the company's annual budget to market to the rural healthcare audience?*
Does the company have an internal marketing department?*

YesNo
Does the company have a Diversity, Equity and Inclusion policy? If so, briefly describe:*
Rural Heathcare References

Please note: Only hospital or clinic references will be accepted.
Reference #1
Organization Name*
Contact Name*

First NameLast Name
Contact Title*
Contact Phone*

Area CodePhone Number
Contact Email*
example@example.com
Description of business relationship*
Length of relationship*
Reference #2
Organization Name*
Contact Name*

First NameLast Name
Contact Title*
Contact Phone*

Area CodePhone Number
Contact Email*
example@example.com
Description of business relationship*
Length of relationship*
Reference #3
Organization Name*
Contact Name*

First NameLast Name
Contact Title*
Contact Phone*

Area CodePhone Number
Contact Email*
example@example.com
Description of business relationship*
Length of relationship*
Reference #4
Organization Name*
Contact Name*

First NameLast Name
Contact Title*
Contact Phone*

Area CodePhone Number
Contact Email*
example@example.com
Description of business relationship*
Length of relationship*
Reference #5
Organization Name*
Contact Name*

First NameLast Name
Contact Title*
Contact Phone*

Area CodePhone Number
Contact Email*
example@example.com
Description of business relationship*
Length of relationship*
Authorized Signature*
Should be Empty:

NRHA Rural Hospital Partnership Application

Organization Details

Rural Heathcare References

Reference #1

Reference #2

Reference #3

Reference #4

Reference #5