Affiliate Application

Enter Company Information:
Company name
Address
 Address 2
City
 State
 Postal Code
 Country
Phone Number
 Website (example: www.ilmgma.com)
Contact name
 Email Address

Requirements for Inclusion in the Affiliate Directory:
In order to be listed in our Affiliate Directory, you must be an active Affiliate Member of the ILMGMA for the current calendar year. If you are not currently an Affiliate Member, but would like to become one, please complete an ILMGMA Membership Application. Once your membership is activated, your Affiliate Directory Application will be processed and your information posted on the website.

(Questions? Please contact main@ilmgma.com.)

Select Affiliate Directory Categories
(Please select no more than three):
Ancillary Services
Architectural/Design
Banking/Financial Services
Billing/Coding & Financial
Collection Agency
Consulting Services
Diagnostic Services
Electronic Data Interchange
Electronic Medical Records
Employee Benefits
Employment/Recruitment
Executive Education
Financial Management Tools
Information Systems/Software
Insurance		 Interoffice/Patient Communications
Management Services
Medical Equipment
Medical Records
Medical Transcription Service
Office/Healthcare Furniture
Office Systems/Supplies
Periodicals/Publications
Pharmaceutical Manufacturer
Physician Office Laboratories
Practice Management
Relocation Services
Staffing Agency
Website Developers
Other

Enter Company Description:

Upload Company Logo: (Recommended size is 400 X 60)


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