Membership Application Organization Contact InformationName of Organization*Organization Contact Name* First Last Organization Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone*Contact Email* Organization Website #1 (client)*Organization Website #2 (donor, if separate from client website)*CEO/Executive Director Contact InformationCEO/ED Name* First Last CEO/ED Office Phone*CEO/ED Cell PhoneCEO/ED Email* How long have you been the leader of this organization?*Organization InformationWhat year was your organization incorporated?*What is the budget for your current fiscal year?*What is your corporate mission statement?*Are you a medical clinic or in the process of adding medical services?*YesNoWhat medical services do you offer?*What non-medical services do you offer?*Does your organization have multiple locations? If so, how many?How many staff are employed at your organization?*Provide the first and last name, title, and email address for those you want to receive PMC Network communications.Board of DirectorsHow many board members do you have currently?*Is your board functioning as a working, managing, or governing board?*Working BoardManaging BoardGoverning BoardHow would you rate the governance knowledge of your board?*ExcellentGoodFairPoorAcknowledgementName of Person Completing this Application*I hereby acknowledge and understand that by completing and submitting this application form, my organization is applying for membership to the PMC Network. Membership to the PMC Network is not guaranteed as membership decisions are based on the organization's qualifications and final membership decisions are made at the discretion of the membership committee.*YesNoReferred By (Name of Contact or Organization)Next StepsAfter you submit your application, someone from the PMC Network team will contact you using the email provided to set a date for a phone interview. Thank you for completing this application. We look forward to getting to know you better. You will be hearing from us soon.