NRHA Partnership Application Form
Managed by NRHA Services Corporation
Name of person completing the application
*
First Name
Last Name
Title
*
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Name of person to sign the contract. Ultimate Decision maker
*
First Name
Last Name
Title
*
Email
*
example@example.com
Organization Details
Organization
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Website URL
*
Year founded
Legal Name
*
Short description of services and solutions the company offers
*
How many rural facilities is the company currently working with now?
*
0-5
6-15
more than 16
we are not in any rural facilities yet
Which one best describes the company?
publically traded
privately owned
If you know it, what is the company's annual budget to market to the rural healthcare audience?
Does the company have an internal marketing department?
Yes
No
Does the company have a Diversity, Equity and Inclusion policy? If so, briefly describe:
Rural Heathcare References
Hospitals and Clinics
Reference #1
Organization Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Contact Phone
-
Area Code
Phone Number
Contact Email
*
example@example.com
Description of business relationship
*
Length of relationship
Reference #2
Organization Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Contact Phone
-
Area Code
Phone Number
Contact Email
*
example@example.com
Description of business relationship
*
Length of relationship
Reference #3
Organization Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Contact Phone
-
Area Code
Phone Number
Contact Email
*
example@example.com
Description of business relationship
*
Length of relationship
Reference #4
Organization Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Contact Phone
-
Area Code
Phone Number
Contact Email
*
example@example.com
Description of business relationship
*
Length of relationship
Reference #5
Organization Name
*
Contact Name
*
First Name
Last Name
Contact Title
*
Contact Phone
-
Area Code
Phone Number
Contact Email
*
example@example.com
Description of business relationship
*
Length of relationship
Authorized Signature
*
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