Affinity Partner Program

KHA's Affinity Partner Program Application

Company Information
Legal Business Name* (DBA):
Street Address:
City:		State	Zip Code:
Telephone Number: *
Fax Number:
Web Site Address:
Executive Contact Infomation
Executive Contact:
Title:
E-mail address:
Contact Information	Information will be sent to this address
Contact name: *	(Same as Above)
E-mail address: *	(Email will be sent to this address)
Product/Service Description: * (What service do you offer)
Two References:
1. Hospital/Organization:*
Contact Person: *

2. Hospital/Organization:*
Contact Person: *
Additional Information
How did you find out about the Affinity Partner Program?*
Which Kentucky hospitals do you currently doing business with?*

*Required Fields