CAHSAH Affiliate Application - Basic Organization Information (Page 1)


Welcome to the CAHSAH online Affiliate application. Affiliate, and Associate dues are $750 per year. 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)      
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