New England Rural Health RoundTable

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Individual Membership Application

Please use this application for Individual Membership in the New England Rural Health RoundTable. We also offer Organizational Memberships and Corporate Memberships.

Need help? For more information or assistance, please call 802-453-5475 or email

Please complete one of the forms listed below:

Use Individual Application Form 01 (To pay offline by mail)
Use Individual Application Form 02 (To pay online with credit card)
Download the printer-friendly Application (PDF/81KB)

Individual Application Form 01 (Complete this form to pay offline by mail)

The cost of Individual Membership is $50.00. Please make checks payable to: New England Rural Health RoundTable, and mail payment to: New England Rural Health RoundTable, P.O. Box 72, Starksboro, VT 05487.

* Required

Individual Information

Member Name

Mailing Address *

City *

State *

Zip *

Phone *

Email *

Please check all committees you are interested in joining:

By-Laws	Finance	Nominating

Membership	Conference

Policy	Communications

Membership Communication

Yes! I would like to receive the following content-specific updates:

List your state(s):

When available, I would like to receive information pertinent to:

I understand that I become an associate member of the National Rural Health Association with my membership in NERHRT and I would like to receive email updates from them.

* NoSpam! verification question: 4 + 2 equals...

To pay offline (by mail)

Thank you for joining the New England Rural Health RoundTable.

Individual Application Form 02 (Complete this form to pay online with credit card)

The cost of Individual Membership is $50.00. PayPal is the secure payment processor for the NERHRT Membership Application. Complete and submit this form to pay securely online using your credit card.

* Required

Individual Information

Member Name

Mailing Address *

City *

State *

Zip *

Phone *

Email *

Please check all committees you are interested in joining:

By-Laws	Finance	Nominating

Membership	Conference

Policy	Communications

Membership Communication

Yes! I would like to receive the following content-specific updates:

List your state(s):

When available, I would like to receive information pertinent to:

I understand that I become an associate member of the National Rural Health Association with my membership in NERHRT and I would like to receive email updates from them.

* NoSpam! verification question: 4 + 2 equals...

To pay online (credit card)

Thank you for joining the New England Rural Health RoundTable.

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P.O. Box 72, Starksboro, VT 05487 - Phone: 802.453.5475

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