CAHSAH Affiliate Application - Basic Organization Information (Page 1)

 

Welcome to the CAHSAH online Affiliate application. Affiliate, Associate, and Registry / Referral Agency dues are $650 per year. Individual dues are $150 per year and are restricted. Please call the membership department for more information about how to qualify. The next several pages will allow you to apply for CAHSAH benefits and either pay online with a credit card or check by mail. If you choose to pay by check, this process will create an invoice which can be included with your check. If you choose to pay by credit card, you will be directed to a secure credit card page which will ask for your credit card information. Fields marked with an * are required fields. Thank you very much for using this system.
*Affiliate Type:    Affiliate (consultant / vendor)     Associate (out-of-state provider)  
  Registry / Referral Agency        
*Application Type:    Renewing      New  
*Company Name: 
*Key Contact:  Title: 
*Company Address:  *City: 
*State:  *Zip Code: 
*Telephone:  Fax Number: 
E-Mail:  Web Address: 
Yes, we want to receive information via email only
*Payment Method:    Mail In Check      Online Credit Card  

Conditions of Participation
  I Agree      I Do Not Agree