THSA Collaboration Council Application

Full Legal Name

Preferred Name

Physical Home Address (not required)

City, State, Zip (not required)

Mailing Address

City, State, Zip

County

Work Telephone

Home Telephone (not required)

Cell phone

Preferred Email Address

Secondary Email Address:

Employer

Employer's Address

Job Title

Health Care Sector

Job Description

What business or professional interests do you have in health information exchange?

Please state your reason for submitting an application for this council:

Agree

Disagree