NRHA Rural Hospital CEO Certification Program Application

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First Name

Last Name

Job Title

Current Position

Facility

City

State

Mobile Phone

Work Phone

How many years have you worked in your current position?

How many years have you worked at a rural hospital?

How many years have you worked in rural health?

Why do you want to participate in this program?

Where do you want to be 5 years from now?

What is the best way to contact you?

Are you a Member of the National Rural Health Association (NRHA)?

Are you a Member of the American College of Healthcare Executives (ACHE)?

Are you a Member of your State Hospital Association?

Please list any other professional associations you are a member of:

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