Renewal Form Membership Business Association - Excel

Document Sample
Renewal Form Membership Business Association - Excel Powered By Docstoc
					                                                                    MEMBERSHIP RENEWAL APPLICATION 2011
                                                                       This info is due by JULY 15
                                                           NAME OF AGENCY

                                                           CONTACT PERSON

PHONE                                                      MAILING ADDRESS
FAX
EMAIL ADDRESS of contact person:

Renewal Type:
Full agency membership:               Open to providers of community-based                   Affiliate membership: Open to associations that do not
behavioral health or other human services, or consumer organizations                         provide community-based behavioral health or other human
representing recipients of such services, which meet criteria for CBH                        services, or do not qualify for membership status as a consumer
membership.                                                                                  organization, but support the mission of CBH.
List total revenue received in providing behavioral health services to children
and adults with mental illnesses and/or substance use disorders in Maryland                  List total revenue related to behavioral health services in Maryland
based on your most recent audited fiscal year:           __________________                  for your most recent audited fiscal year: _____________
1) Multiply the first $3 million by .0023                                                    If your revenues are under $250,000 dues are: $750
2) Multiply the balance up to $10 million by .001                                            If your revenues are over $250,000 dues are: $1,000
3) Multiply any balance over $10 million by .0005
Dues are the total of #1, 2 and 3.

                        Check here if you'd like to pay your dues quarterly. You must include the 1st qtr payment with this renewal form.
To be considered a member of this association, this form and all required documentation is to be submitted prior to the end of the September or all
mailings will cease until the information is provided.
Please provide the following information with your renewal form or indicate when CBH will receive this information.

             Annual Audited Financial Statement                        Member Profile Form                                          Updated brochure

CBH encourages participation in our various committees, task forces and workgroups by staff of all full member agencies. Please provide the name and
email address of your agency rep to each of the committees listed below. This person will serve as our contact for information regarding each respective
committee.



                                                                                                                       Mail all 3 pages of the renewal form to:
continued on page 2                                                                                                    CBH, Inc., 18 Egges Ln, Catonsville, MD 21228
                                                                                                                       410.788.1865 for questions
CBH Committee Reps for (Agency Name)_________________________________________________________________________                                                 page 2 of CBH
       (All committee/workgroup meetings are held at CBH unless noted below)                                                                                  member renewal


Child & Adolescent: Name:                                                                     Email address: _____
           meets the 1st Friday of each month 10am

Clinical:                Name:                                                                Email address: __________________________________________
              meets the 4th Wednesday of the month at 9:30am

Compliance:         Name:                                                                     Email address: __________________________________________
          meets by phone the 2nd Tuesday of every other month at 9:30am

Integrated Care:     Name:                                                                    Email address: __________________________________________
           meets by phone the 1st Monday of every other month at 3:30pm

* Provider Business Affairs:    Name:                                                         Email address: __________________________________________
  * meets by phone
            meets the 2nd Monday of each month at 1:30pm

Professional Training & Development:         Name: ________________________           Email address: _________________________________________
           meets the 4th Thursday of each month at 1pm
           subcommittee: Curriculum Development         Name: _____________________ Email address: _________________________________________
                       meets the 2nd Friday of the month at 9:30am as needed by phone

Rehab & Community Support:              Name:                                                 Email address: _________________________________________
         meets the 2nd Wednesday of each month at 10am

Vocational:              Name:                                                                Email address: _________________________________________
              meets the 1st Wednesday of each month at 10am

              Please note that information regarding any of these committees is available in the "members only" section of the
              CBH website: www.mdcbh.org

              Please contact the CBH office if you need access info to open these sections of the website.           Mail all 3 pages of the renewal form to:
                                                                                                                     CBH, Inc., 18 Egges Ln, Catonsville, MD 21228
                                                                                                                     410.788.1865 for questions

				
DOCUMENT INFO
Description: Renewal Form Membership Business Association document sample