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  1. Complete this application by including your senior leadership contact information and your website URL.
  2. Give a brief description of the products/services your organization offers to HIEs.
  3. The SHIEC Board will review your application and determine your eligibility to join.
  4. You will be notified of the Board’s decision or contacted for additional information if necessary.

    Organization Information

    Senior Leadership Contact Information:

    Person Completing this form, if different from above:

    Describe Your Company’s Products and Services Offered to HIEs (limit 100 words):

    Examples of your current HIE customers:

    Organization Size and Annual Membership Fees

    Please indicate your organization’s* gross annual revenue category:

    If your organization has multiple operational divisions you may use the gross revenue of the operating unit that sells to HIEs.

    Less than $5 Million: $7,500/year feeBetween $5 and $10 million: $12,500/year feeBetween $10 and $50 million: $17,500/year feeMore than $50 million: $27,500/year fee