Membership - Michigan Healthcare Cybersecurity Council

Become a member

To view the MiHCC membership guidelines: Membership Packet PDF.

MiHCC MEMBERSHIP INQUIRY FORM:

All fields are required

Individual Information

Name

Title

Phone

Organization Information

Name

Website

Phone

Street

City

State

Zip

Membership Type Requested

Organization Type

Ownership Type

Primary Contact Information

(if different from Individual Member Information)

Name

Title

Phone

Release/Authorization (must check one)

Yes – I authorize the use of my name, photograph, event information and Organization Information in MiHCC Inc. promotional materials including but not limited to websites and press releases. This authorization does not permit the use of any trademarked or copyrighted logo’s. Yes – I authorize the use of my name, photograph, event information and Organization Information in MiHCC Inc. promotional materials subject to limitations. No – I do not authorize any use of my name, photograph, event information and Organization Information for MiHCC Inc. promotional purposes.

* Please note regardless of the choice indicated certain member information may be included as required for governmental filings.

Purpose for joining MiHCC

Related Memberships

Certification

(To be signed by the Chief Executive Officer or his/her designee)

I certify on behalf of my organization that I have read the bylaws of MIHCC Inc. and agree to support the purpose and objectives of the corporation. I understand that this application, upon being filed, will be referred to the MIHCC Inc. Board of Directors for consideration. I also understand that before becoming a member, remit the specified dues for membership level must be submitted.

Full Name of CEO or Designee:

Title

Date