Tampa Bay Healthcare Collaborative - Membership Application

Name
Title
Organization
Address
City
State
Zip Code
Telephone
Fax
E-Mail
Web Site
   
Please describe the mission and purpose of your organization and briefly describe the services provided.
Briefly discuss why you are making an application for membership. What does your organization hope to gain from participation and how could it be of assistance in our efforts?
Are you aware of any activity in which you are engaged, personally or professionally, that would constitute a conflict of interest with the purpose, mission, and/or focus of the Tampa Bay Healthcare Collaborative? If yes, please explain
May we list your organization as a Tampa Bay Healthcare Collaborative member in our literature?