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2010-2011 OHIMA Consultant Roster Membership Application

Complete the following information. Upon successful submission, you will be directed to payment instructions via the Telusys Customer Service Center to complete your application. Only Visa and MasterCard payments are accepted.

^*FIRST NAME:

^*LAST NAME:

CREDENTIAL(S): (Please separate each credential by a comma)

COMPANY/ORGANIZATION:

^*ADDRESS 1:

ADDRESS 2:

^*CITY:

^*STATE:

^*ZIP CODE:

COUNTRY:

^*WORK PHONE (XXX-XXX-XXXX):

FAX:

TOLL-FREE NUMBER (if applicable):

^*EMAIL ADDRESS:

WEBSITE ADDRESS (if applicable):

DESCRIPTION/ADDITIONAL COMMENTS ABOUT YOUR BUSINESS OR SERVICES (optional):

^*By applying to the OHIMA Consultant roster, I consent to my information being posted on the OHIMA Web site.

Yes
No

^*I would like to receive the weekly e-newsletter "Capitol Connection," a Long Term Care Update from AHCA/NCAL. View sample publication.

Yes
No

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