Online Corporate Affiliate Application

The NHMS Council will approve or deny corporate affiliate program membership based on the following guidelines:

1. The company’s product or service is
   1. deemed of potential interest to physicians on a personal or professional level
   2. consistent with the values and mission of the Medical Society
   3. not intrinsically harmful to or obstructive of the public health or welfare of physicians and/or patients
2. The company’s marketing of products and services is not misleading or inconsistent with the values and mission of the Medical Society.
3. Companies whose sole purpose or commonly recognized purposes are among the following will generally not be considered for membership: manufacturing of tobacco or related products; or the marketing of religious or political products or services.

By filling out the application below you are stating that you meet the above qualifications for review by the council.

Name *

First

Last

Title

Company Name *

Billing Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email (that you want for NHMS communications) *

Website

Category (i.e, insurance, legal)

Brief company description

Phone Number *

NHMS Member Reference:

Please list other company employees who should receive our mailings: name/title/email

1.

2.

3.

Comment or Message

Electronic Signature of company representative and title *

Today's Date

Submit Application