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QHN New Membership

Membership Information 2008/2009

Key Organizational Contact

Name

Title

Organization

Address

City

Province

Postal Code

Phone

Fax

Email

 

Membership Categories 2007/2008

Health Care Provider Member or Business Enterprise Member

QHN Members - $5500 + GST = $5830


GST# 89182 7420 RT0001

Don't forget to complete the key contact information for your organization!

 

Organizational Key Contacts 2007/2008

Please identify the key contacts for your organization. Key contacts will receive all faxes and mailings and act as a dissemination point for all the many products and services that the Quality Healthcare Network offers. Please copy this form as required.

Health Care Provider Member and Business Enterprise Member - 3 other key contacts

Name

Title

Organization

Address

City

Province

Postal Code

Phone

Fax

Email

 

Name

Title

Organization

Address

City

Province

Postal Code

Phone

Fax

Email

 

Name

Title

Organization

Address

City

Province

Postal Code

Phone

Fax

Email

 

Print this form and mail it with a cheque made payable to:
The Quality Healthcare Network, 790 Bay street, 9th floor, Toronto, Ontario, M5G 1N8.