AHHA INSTITUTIONAL MEMBERSHIP APPLICATION


MEMBER INFORMATION:
Organization Name:
Tax ID Number:
Street Address:
City:
State:
Zip Code:
Country:
Office Telephone:
E-mail (optional):
Web Site (optional):
Contact Person/Title:
Contact's Phone/E-mail:

MEMBER LISTING:
Healthcare Approach:


Patient Access:


Center follows a Holistic (whole person) Philosophy?:


Treatment Therapies available for patient care at Center (limit about 250 characters):


Focus of Center -- Describe important, unique factors of what Center offers, such as specific disease conditions treated, success rates, staff team approach, insurance coverage (limit about 250 characters):
IMPORTANT - List full names of three key staff healthcare practitioners, who treat patients. Indicate which modalities each is trained and legally authorized to deliver:


Yes, we grant permission for release of the authorized information for the Healing Centers in North America networking list and other public relations opportunities.

Yes, our center wants to become an Institutional Member of the American Holistic Health Association and certifies that the information provided above is accurate.



Signature of Authorized Representative ______________________________________________


Date ____________________

NOTE: If you elect to submit this form using our online option, you will need to fill in the Signature box below. By typing your full name and today's date in this box you are providing the legal equivalent to your signature in response to the above questions.
SIGNATURE: (enter your full name and today's date)


CONTRIBUTION INFORMATION:
MEMBERSHIP
We support the vital work of AHHA!
The leading nonprofit wellness and healing information resource, valued by many of the foremost healthcare professionals in America.
$___110____ is our AHHA Institutional Membership annual contribution
$__________ For foreign addresses, add $10 toward extra postage costs

[Please consider additional support]

ADDITIONAL GIFT
We understand that nonprofit AHHA remains free and impartial only through donations. In fact, AHHA's work is funded solely by contributions. Therefore, we want to contribute an additional amount to expand the outreach of this valuable organization, where people are connected with self-help resources through www.ahha.org so they can become active participants in enhancing their health and well-being. As the free and impartial wellness resource, AHHA is increasing the number of health-conscious consumers worldwide -- thus, creating more interest in what integrated centers offer.
$__________ Along with our membership contribution, we are enclosing an additional gift
$500 Platinum Circle
$250 Gold Circle
$100 Silver Circle
$50 Bronze Circle
$5-$49 Extra Gift
These extra donations over and above the basic membership contribution amount are acknowledged in the Honored Donors section of our website with the name of the donor. Gold and Platinum Circle level donors can add a hyperlink.
We grant permission to be added to the Honored Donors list
$ OUR TOTAL SUPPORT TO AHHA (Membership contribution PLUS any additional donation)
AHHA is a designated 501(C)(3) - Tax ID# 33-041271
Contributions are tax deductible as allowed by law

SUBMITTAL OPTIONS:
(Option 1) To pay by check, money order or credit card by mail...
Click here for form to download, printout, complete and mail in.

(Option 2) To pay by credit card using online Secure Server...
AHHA accepts Visa, MasterCard and Discover
  • Fill in ONLINE on this screen all information requested above
  • Print out a copy of all of the above for your records
  • Click on Pay Online button below
  • Follow directions to enter and submit credit card data
To pay by credit card online, click the Pay Online button below.
You will be transferred to the Authorize.net Secure Server, and asked for your credit card information.
Once you have transferred to the secure server, you will be asked to...
Enter Credit Card Number and Expiration Date
Under "Customer Billing Information"
Enter Cardholder Name and Billing Address for Card
If you enter your E-Mail Address, you will receive an immediate e-mail notification of your transaction from the credit card operation.
AHHA will acknowledge your credit card transaction by notifying you of the authorization code.

Credit Card Processing