PHA Membership Application (Step 1)

One-year membership fee is $100 per year.


First Name


Last Name


Modality


License No. or Certification Info.


Address


Address


City


State


Zip


Phone Number


Email


Website


PHA Member Who Referred You


Reference #1 Name


Reference #1 Contact


Reference #2 Name


Reference #2 Contact


Retype your name here.
By my electronic signature, I am giving consent for Portland Health Alliance to contact me, my references, and to verify any license or certificate information for the purpose of processing my application.

If you are not automatically redirected, return and CLICK HERE to complete your application.