subject_line
Company Name
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Fax Number
*
Company Email Address
*
Website
*
# of Offices:
*
# of Employees:
*
Date of Formation
*
Head of Company
First Name
*
Last Name
*
Job Title
*
Phone Number
*
Email Address
*
Association Contact (if different)
First Name
Last Name
Job Title
Phone Number
Email Address
Are you BEP certified?
*
Yes
No
Please supply a 250-500 word description of your company which will be sent to members of IAMHP.
*
I’d like to receive marketing new alerts and other communications from IAMHP.
*
Yes
No
Payment Information
I authorize IAMHP to charge the following credit card in the amount indicated below for my annual Trusted Partner membership fee:
*
Trusted Partner Annual Membership ($5,500)
Trusted Partner Annual Membership with Provider/BEP Discount ($4,500)
Card Number
*
MM/YY
*
CVV
*
Name on Card
*
Zip / Postal
*