Affiliate Application

Name

This field is for validation purposes and should be left unchanged.

Please complete the application and attached all required documents. If you have any questions, please contact Lisa Fisher, Vice President of Member Relations.

I am applying as an...*

Please upload a copy of your Studend ID:*

Max. file size: 24 MB.

Name*

Prefix First Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Phone*

Organization Name*

Organization Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization CEO, President or Director*

Prefix First Last Suffix

Mission Statement*

Licensed since (if applicable)

Additional Locations?*

Yes

No

Directory of Locations

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Please upload a directory of all you clinic locations. Upload as doc, docx, or pdf file

Organization Website*

Contact Information

Contact Name*

Prefix First Last Suffix

Contact Title*

Address*

Same as Above

Different than Above

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Email*

Please provide contact information of your staff in the following positions

Chief Financial Officer

Prefix First Last Suffix

Chief Financial Officer Email

Chief Financial Officer Phone

Medical Officer

Prefix First Last Suffix

Medical Officer Email

Medical Director Phone

HIT Manager

Prefix First Last Suffix

HIT Manager Email

HIT Manager Phone

Director of Pharmacy

Prefix First Last Suffix

Director of Pharmacy Email

Director of Pharmacy Phone

Operations Manager

Prefix First Last Suffix

Operations Manager Email

Operations Manager Phone

Financial Information

Federal Tax ID #*

Fiscal Year End (Month)*

Gross Operating Cost*

Required Documents

Federal Tax Exemption as 501(c)3*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as .doc, .docx, or .pdf

List of your Board of Directors, with officers noted*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as .doc, .docx, or .pdf

Electronic Logo*

Max. file size: 24 MB.

Marketing Material (Optional)

Drop files here or

Max. file size: 24 MB.

Affiliate Agreement

This signature certifies that the party/parties above and whose signature appears below is the official delegate to the Community Clinic Association of Los Angeles County (CCALAC). If an organization, the delegates have their primary employment at the organization listed on this application. By signing you agree that you have no conflict of interest with other CCALAC member or affiliate agencies. If there is a change in your delegates, a written notification will be sent to CCALAC. This also represents your organization’s agreement to the activities of the CCALAC. It is understood that all information provided will be treated confidentially.*

Use mouse to sign.

Signatory's Name*

First Last

Date*

Upon approval of the affiliate application by CCALAC’s board of directors, CCALAC will send an invoice to the primary contact listed on this application.