Organization information

Your organization's Full Legal Name 

   *  Enter name

Your organization's "Doing Business As" Name (if different from the legal name)

 

Address	*  Enter address
City	*    State   *  Zip   *

Please specify whether your organization is a * Health Plan Employer Provider Vendor Other (please specify)   Enter type Enter type

                Enter city                             Enter state                 Enter zip          

How the Survey results data will be used.
     Please state to whom the results will be distributed and how the data will be used.

*

   Enter how the results will be used

* Please indicate which of the following you are requesting by checking one of the boxes:   Please select either internal use or distribution use

Internal Use Only Distribution Use
Internal Use: Data can be used for purposes internal to the organization but may not be used for public display.	Distribution Use: Data can be used for public display; for internal use; and for distribution to other organizations for use.

Primary Contact

Name	*  Enter name
Title	*  Enter title
Phone	*  Enter phone
Fax
Email	*  Enter email
Address
City	State Zip

Accounts Payable Contact

	Same as primary contact
Name	Enter name
Title	Enter title
Phone	Enter phone
Fax
Email	Enter email
Address
City	State Zip

Person completing this application

	Same as primary contact
Name	Enter name
Title	Enter title
Phone	Enter phone
Fax
Email	Enter email
Address
City	State Zip