INSTITUTE OF INTEGRATED HEALTHCARE (IIH)
MEMBERSHIP APPLICATION
NAME OF APPLICANT:
Position or Rank
Credentials/Certifications
Mailing address
Email address
Telephone
AFFILIATION TYPE
The University of Texas at Tyler Other Institute of Higher Ed. Community Partner
College College Business/Agency/Foundation
Dept. Dept. Name
Chair Chair Purpose
Dean Dean Contact
How can the IIH assist in the advancement of your goals? (check all that apply)
Educational programs or classes
Health promotion activities or exercise
Identify or Review Grants
Help with building partnerships
Financial Support of Research
How can your contributions advance the mission of the IIH? (check all that apply)
Provide educational programs (conferences, programs, classes)
Lead health promotion activities or exercise
Review grants/publications
Partner with others to advance integrated healthcare research
Support the IIH financially
1 of 2
Provide a brief summary of your research, education, and/or practice goals as they relate to the IIH. (Attach
a current copy of your CV or Resume.)
IIH Director/Date Associate Director/Date
2 of 2
Signature: ________________________________________ Date: ___________________
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