PartnersVA.com Member Signup

Please fill out the form below to signup for membership. Visa, MasterCard, American Express, and Discover cards are accepted.

Dues are paid annually based on the day you join.

Member Information

Member Type *
CBS Link
Company Name *
Licensing Authority *
Website (link)
Facebook (link)
Twitter (link)
Street Address *
City *
State *
Zip *
Referred By *
Are you licensed in the Commonwealth of Virginia? *
Username *
Password *

Contact Name [1] *
Title *
Email Address *
Primary Phone *
Cell Phone
Fax Number
Supervisor's Email *
Contact Name [2]
Title *
Email Address *
Primary Phone *
Cell Phone
Fax Number

Company Overview

Please provide detailed information about your organization. You may type (or copy & paste) information into the box below. Company Overview is what the public will read about your organization (and search engines too). Tips: Use strategic keywords that are specific. Incorporate words and phrases for services that your customer will be searching to find you.

Service Areas

Please click each Service Area where your company provides service.
When clicked, service area will move to the "Selected" column below.

Service Areas

Service Areas out of RMSA

List your locations out of RMSA $50.00 each - includes One Picture of Location

Areas out of RMSA
State

Category Selection

1. Select one or two Categories below. Category=Directory tab. Be sure you are listing your organization properly.

2. You must select at least one Service for each Category you select. Services will appear after Category selection is made below.

Category [1] *

Category [2]

Enhance Your Listing

What do you get with an Enhanced Listing?

Inclusion in rotating banner ad on our Home page
Company logo at the top of one directory category
Highlighted Directory Listing, moved to the top of the category's listings. First come first served basis. If you're the first in your category to enhance your listing, you will be listed first!
Easy access by Web site visitors to your company overview, products, services, and more.

What is the cost?

$275.00 for the duration of 2011 and the 2012 calendar year.

Enhance My Listing (optional)

Member Agreements

Submit Individual Networking Agreement

Print PartnersVA - Individual Networking Agreement
Sign & date your printed copy mail signed copy to: Partners in Healthcare of Virginia, LLC
Attn: Membership
136 West Square Court
Richmond, VA 23238

I have read and agree to PartnersVA - Individual Networking Agreement

Submit Visitation Policy Agreement

Print HCA Hospitals Vendor Visitation Policy
Sign & date your printed copy mail signed copy to: Partners in Healthcare of Virginia, LLC
Attn: Membership
136 West Square Court
Richmond, VA 23238

I have read and agree to HCA Hospitals Vendor Visitation Policy

Important Notice about Luncheons

Partners must pay for luncheons no less than one week in advance of luncheon date. If a Partner cannot keep the scheduled dated listed on the lunch rotation list, they are responsible for their portion of payment unless a Partner from the will-call list can fill that spot.
Partners must be accountable for your Partnership participation just as you would for your individual businesses.

I have read and agree to Partners in Healthcare Policy and Procedures

Billing Information

Billing Address *
City *
State *
Zip *
Payment Method *

Please mail check to:

Partners in Healthcare of Virginia
Attn: Membership Dues
136 West Square Court
Richmond, VA 23238

Please make check amount the same as transaction total below.

After check is received we will email you so you can access the website.
Please fill out the online payment form after your click signup button.

After the online payment is received we will email you so you can access the website.
Name On Card *
Card Number *
Card Cvv *
Expiration Date * /

Transaction Total: $0.00