MHA Corporate Affiliate Membership Application Question Title * 1. Organization Question Title * 2. Address 1 Address Address 2 City/Town State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Phone Number Question Title * 3. Organization Website Question Title * 4. Contact Name Question Title * 5. Contact Title Question Title * 6. Contact Email Question Title * 7. Contact Phone Question Title * 8. Name of CEO Question Title * 9. CEO Signature PDF, DOC, DOCX, PNG, JPG, JPEG file types only. Choose File Choose File No file chosen Remove File CEO Signature Question Title * 10. Date Question Title * 11. Please include a brief statement explaining the primary business product or service of your organization and its relationship to Maryland’s health care industry. Submit Application