Corporate Affiliates Application

Please complete the form below to submit your application. If, for whatever reason, you cannot submit your application electronically, a paper form is also available.

Company Information
Company Name*
Headquarters Address:*
Street Address Address Line 2 City State ZIP Code
Name of person completing this form:*
First Last
Email*
How did you learn about Corporate Affiliates?*
Primary Contact Information
Name:*
Prefix First Middle Last
Email:*
Phone:*
Position:*
Is the primary contact listed above based elsewhere than your headquarters?*
Mailing Address of Primary Contact*
Street Address Address Line 2 City State ZIP Code
Alternate Contact Information
Name:
Prefix First Middle Last
Email:
Phone:
Position:
Company Details
Please specify:*
Please choose a category to classify your agency:*
Please specify:*
Please provide a brief summary of your company, services, or products. We encourage you to tailor it to the homeless health care context:*
Company Website:
Please acknowledge our approval policy:*
- I acknowledge that my Corporate Affiliate application with the National Health Care for the Homeless Council is subject to approval by the Council’s leadership, and that Affiliation does not necessarily constitute an endorsement by the National Health Care for the Homeless Council.
Determine your rate:*
Total
$0.00
Important Note:
Once your application is submitted, you will be contacted by Andrea Crowe to arrange payment and finalize your membership. After clicking submit, please email a high-resolution image of your logo to bwatts@nhchc.org. If, for whatever reason, your application is not approved, we will reimburse your payment.
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Email
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Corporate Affiliates Form

Corporate Affiliates Application

Company Information

Primary Contact Information

Alternate Contact Information

Company Details

Important Note: