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HSDA Membership Application

Please supply all information below or Download the membership application here (.docx). Approval of your application is subject to review by the Membership Committee.

Basic Company Information

Today's Date
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Membership Status(*)
Please check the box to confirm that you are a new applicant vs. renewing your membership.

Please confirm that you are applying for new membership. If you are renewing, please go to memberships.

Company Name(*)
Please enter your company name.

Company Website(*)
Please enter your company website address.

http(s):// required

DUNS#
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Company Size (By Revenue)(*)
Please indicate your company size.

Company Size (By Number of Employees)(*)
Please select your number of employees.

Industry(*)
Please select your industry.

Please Specify
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Primary Contact Information

Primary Contact Name(*)
Please type your full name.

Job Title(*)
Please enter your job title.

E-mail Address
Please enter a valid e-mail address.

Phone Number
Please use the following format: 123-456-7890

Please use the following format: 123-456-7890

Street Address(*)
Please enter your street address.

City(*)
Please enter your city.

State(*)
Please select a state.

Zio Code(*)
Please enter a valid zip code.

Formats: 12345 or 12345-1234

 

CEO Contact Information

Contact Name
Please type the full name of your CEO.

Job Title
Please enter your job title.

E-mail Address(*)
Please enter a valid e-mail address for your CEO.

Phone Number(*)
Please use the following format: 123-456-7890

Please use the following format: 123-456-7890

Street Address
Please enter your street address.

City
Please enter your city.

State
Please select a state.

Zio Code
Please enter a valid zip code.

Formats: 12345 or 12345-1234

 

Questionnaire

Company Summary(*)
Please provide some basic information about your company.

Please summarize in 100 words or less the nature of your business and include where the company is headquartered, how long in business, etc.

Involvement(*)
Please let us know why you are applying for membership so that we can support your goals.

Please tell us in 100 words or less why you or the company would like to be a part of HSDA.

References or Recommendation

In order for you or the company to be considered for HSDA membership approval, you must either (1) provide 3 references or (2) have a recommendation from a current HSDA member.

Please check one.(*)

Please check one.

Reference #1(*)
For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

Reference #2(*)
For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

Reference #3(*)
For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

For each reference, please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

Recommendation(*)
Please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

Please provide the following: (1) Name, (2) Company Name, (3) Phone Number and (4) E-mail Address.

Membership Category (Annual Dues)(*)

Please choose a membership category.

Payments for membership dues are not processed with your application. We only collect dues on approval.

Please upload your certification
Oops! We did not receive your certification. Please try again or contact us at info@hsdafordiversity.org.

As a member of HSDA your company will:

  • Support and promote the HSDA mission, goals and objectives
  • Have or establish a supplier diversity policy or plan
  • Designate a primary contact person for MWBEs wishing to do business with our company
  • Participate in and support HSDA events and activities

The HSDA is a not for profit 501 (C) 6 corporation focused on education and awareness of supplier diversity within the healthcare supply chain and does not extend any promise of business to its members. Nothing in any HSDA printed materials or verbal interactions should be construed to imply a promise of business. All officers and directors represent their affiliated organizations.