Organization Name*

Organization Type* Healthcare ProviderHealth IT Vendor / DeveloperHealth Information NetworkPayer / Heath PlanConsumer / Data RequesterAssociationConsultantAccrediting Body / Standards Development OrganizationOther

Contact First Name*

Contact Last Name*

Contact Title*

Email*

Alternate Contact Email*

Alternate Contact First Name*

Alternate Contact Last Name*

Organization Address*

City*

State*

Zip*

Phone*

Web Page URL*

Accounting Contact Email* Please include a general organization email for billing and other related correspondence.

Select Membership Type to Calculate Annual Membership Fee*

Select Revenue/Budget* Federal - Member: $3,500State - Member: $2,500Local - Member: $1,500

Select Revenue/Budget* < $5 Million - Member: $3,500$5 - 25 Million - Member: $7,750> $25 Million - Member: $12,000

Select Revenue/Budget* < 100 hospital beds or <25 physicians / other providers - Member: $3,500100-300 hospital beds or 25-75 physicians / other providers - Member: $7,750> 300 hospital beds or > 75 physicians or other providers - Member: $12,000

Select Revenue/Budget* <$5 Million - Member: $4,500$5 – 24 Million - Member: $8,000$25-99 Million - Member: $13,000$100-499 Million - Member: $17,000>$500 Million - Member: $24,500

I agree to receive electronic communications from The Sequoia Project.* Yes

I agree to Membership Terms and Conditions* Yes View Terms and Conditions In Order to Submit Application