HFA Membership Application

Online Application Form for Membership of the Health Funders Association

Type of application(*)

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Organization details:

Registered name(*)

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Trading Name(*)

Please type your full name.

Registration Number(*)

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Registered Address(*)

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Website Address

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Telephone(*)

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CEO / Principal Officer details

Full Name(*)

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Designation(*)

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Identity No.(*)

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Office Telephone(*)

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Mobile Telephone(*)

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E-mail Address(*)

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Scheme Membership Details:

Total Number of Principal Members(*)

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Total Number of Beneficiaries(*)

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Declaration by head of the applicant organisation:

I declare that, to the best of my knowledge, that the information herein supplied is complete, true and correct and not misleading in any respect.
I hereby confirm that I have the necessary authority to furnish this information and to make the undertakings required herein.
I agree to comply with the rules and terms of membership as laid out in the Memorandum of Incorporation of the Health Funders Association.

Date(*)

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Representative Full Name(*)

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Your Designation(*)

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I Confirm(*)

the Declaration and Agree to the Terms and Conditions.

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Password for Website(*)

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Verify Password(*)

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(*)

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