HT4M Member Information

HT4M Member Information
About Your CEO/Founder
CEO/Founder Name:*

First Name Last Name
We highlight our members by including your CEO/Founder of the company on our website. Please tell us their Title/Position (as you want it on our website):*
CEO/Founder Email:*
example@example.com
CEO/Founder Phone Number:*

Area Code Phone Number
CEO/Founder Twitter Handle:
Upload CEO/Founder headshot:*

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If you have someone who schedules for you, please share their information:

First Name Last Name
Email:
example@example.com
Please list an additional marketing person we should contact with any information we may have to disseminate. This person may be a direct report, a colleague, an Admin, etc.
Name

First Name Last Name
Title
Email
example@example.com

About Your Company
Company Name:*
Website URL:*
Company Twitter Handle:*
Year Founded:*
Headquarters City:*
Headquarters State:*
Upload your company's logo: *

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What type of business is your company?*

Health technology startupPublic or privately held (self-funded) companyHealth PlanHealth System or ProviderNonprofitIndustry ConsultantVenture Capitalist/Fund

Follow up For Non-Profit Organizations
Tell us about your organization's connection to the Medicaid population, and your interest in collaborating with HT4M members.*

Follow Up For Consultants
Tell us about your health sector expertise and the services that you offer clients.*
Are you a former State Medicaid Director?*

YesNo
If you are a former State Medicaid Director, please list the state program(s) that you managed:

Follow Up For Investors, Venture Capitalists, and/or Funds
Date of your most recent fund announcement:*

MonthDay Year
Date
How much was your most recent fund:*
Total fund history:*
Do you currently invest in health technology startups?*

YesNoWe're getting into the sector
If you currently invest in health technology, please list a few portfolio companies:*
Are you planning to announce a new fund in the next 12 months? [This information will be kept confidential and is for record keeping only]*

YesNo
Please list an additional person who should receive our invitations, updates, opportunities and emails. This person may be a colleague, a direct report, an Admin, etc.
Name

First Name Last Name
Title
Email
example@example.com

Membership Dues
Membership dues for 2020 are $5,000. Member registration will not be completed until dues have been received.
I plan to pay my dues (directions will be sent with invoice):*

Via checkVia ACHPlease contact me directly to discuss payment
Name of the accounting contact we should send your membership invoice to:*

First Name Last Name
Email of the person we should send your invoice to:*
example@example.com
Phone Number of Accounting Contact*

Area Code Phone Number
Your business address:*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
By signing below, I certify that my organization will and is able to pay our annual membership dues.
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About Your Company