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Missouri Association of Health Plans

Application for Associate Membership

Applicant Organization’s Name

Address

City                                                                  State                                        Zip Code

Telephone # with area code                                          Fax #

Name of Primary Contact                                                         E-mail Address

Annual associate membership dues are $1,000.00

Please remit to: The Missouri Association of Health Plans

                          P.O. Box 104838

                          Jefferson City, MO 65110

Questions? Email: moahp@earthlink.net or phone Catherine Edwards at (573) 619-6185         

Please select the category which best describes your organization:

       __ Consultant/Contractor               __ Service provider                  __ Academic program                                      __ Academic Institution or department

Please provide a brief description of your organization’s objectives for this membership:

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