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Get Application
How it works
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Open form follow the instructions
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Easily sign the form with your finger
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Send filled & signed form or save
How to fill out the Application online
This guide provides step-by-step instructions for filling out the Application online. By following these instructions, you can ensure that your application is completed accurately and submitted on time.
Follow the steps to successfully complete your Application
- Press the ‘Get Form’ button to access the form and open it in the editor.
- Enter the name of your health delivery organization in the designated field.
- Provide the mailing address of your organization, including the city, state, and zip code.
- Fill in the name of the contact person at your organization, selecting the appropriate title (Mr., Ms., Mrs.).
- Include the phone number and fax number for the contact person.
- Indicate the type of health delivery organization by selecting one of the provided options: Hospital, Health System, Integrated Network, Community Partnership, Other, or Mix.
- Specify the primary type of community served—choose from Urban, Rural, or Suburban.
- List three references who can attest to the commitment of your organization to community service and the impact of your community service initiatives. Provide each reference's name, title, organization, city, state, phone number, and their relationship to your healthcare organization.
- In the signatures section, provide the required names and titles for the Chief Executive Officer, Board of Trustees Chair, Chief Medical Officer, and Application Contact Person. Ensure each name is typed or printed clearly.
- Once all sections of the form are completed, you may save your changes, download a copy, print the form, or share it as necessary.
Complete your Application online and ensure timely submission.
An application file contains all the relevant documents and information related to a submitted application. It serves as a comprehensive record of your application journey, including forms and any additional correspondence. Keeping an organized application file can facilitate quicker responses from authorities and enhance the effectiveness of your application. uslegalforms can assist you in creating and maintaining application files efficiently.
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