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Home > Membership > Membership Application Form
Membership Application Form
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Thank you for your interest in joining the New England Rural Health RoundTable. If you have questions, need information or assistance, please call 603-643-2800 or email

To join the New England Rural Health RoundTable, please complete one of the forms listed below:
Application Form 01 (Complete this form to pay offline by mail)
Please make checks payable to: New England Rural Health RoundTable, and mail payment, or payment and completed printer-friendly Application Form, to: New England Rural Health RoundTable, 10 Benning Street, Box 184, West Lebanon, NH 03784
Individual members, please complete Member #1 information. Organizational members, please complete Member #1, #2, and #3 information
* Required
Membership Type * Fee
Individual $50
Organizational: (3 people total) $125
Member Name #1 *
Work Address *
Phone *
Email *
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
>> Individual Members: Skip to Submit Application
Member Name #2
Work Address
Phone
Email
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
Member Name #3
Work Address
Phone
Email
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
To pay offline (by mail)
Application Form 02 (Complete this form to pay online with credit card)
Individual members, please complete Member #1 information. Organizational members, please complete Member #1, #2, and #3 information
* Required
Membership Type * Fee
Individual $50
Organizational: (3 people total) $125
Member Name #1 *
Work Address *
Phone *
Email *
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
>> Individual Members: Skip to Submit Application
Member Name #2
Work Address
Phone
Email
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
Member Name #3
Work Address
Phone
Email
Web Site
Please check all committees you are interested in joining:
By-Laws Finance Nominating
Membership Conference ?
Policy Communications ?
To pay online (credit card)
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10 Benning Street, Box 184, West Lebanon, NH 03784, 603-643-2800
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