APPLICATION FOR RENEWAL OF
INTERIM ORGANIZATIONAL MEMBERSHIP
IN THE
TEXAS ASSOCIATION OF COMMUNITY HEALTH CENTERS (TACHC)
I. INTERIM ORGANIZATIONAL MEMBERSHIP RENEWAL:
Application for Interim Organizational Membership is available to any non-profit corporation or public entity within the State of Texas that is
· committed to the purposes of this Association, as stated in TACHC’s Articles of Incorporation;
· demonstrates active pursuit of FQHC Look-Alike or FQHC status.
Interim Organizational Memberships are limited to the initial pro-rated year the entity becomes a member. The nonprofit corporation or public entity may reapply for this membership for an additional twelve (12) month term and one extension beyond that if necessary. To continue membership in TACHC, organizations admitted as Interim Organizational Members will be required to apply for Organizational Membership within one hundred and twenty (120) days of their notice of grant award under Section 330 of the Public Health Service Act or FQHC Look-Alike certification. Dues for Interim Organizational Membership are established by the TACHC Board of Directors.
II. REVIEW CRITERIA
TACHC’s Membership Committee and Board of Directors will review an organization’s application for extension to determine that if:
A. Applying for an additional12-month term after initial pro-rated year:
· Demonstrates continued active pursuit of FQHC Look-Alike or FQHC status by:
o providing anticipated/completed date of application for FQHC or FQHC Look-Alike status
B. Applying for an extension beyond initial pro-rated year and an additional twelve (12)
month term:
· Demonstrates continued active pursuit of FQHC Look-Alike or FQHC status by:
o providing proof of pending FQHC or FQHC Look-Alike application OR proof of denial of an application and anticipated date of re-submittal.
Incomplete applications will not be considered for membership in TACHC.
III. GENERAL INFORMATION:
Name of Institution or Organization: ______
Address: ______
City: ______
State: Zip: ______
Phone Number: Fax Number: ______
Web-Site (if applicable): ______
Chief Executive Officer/Executive Director: ______
E-mail Address for CEO/ED: ______
IV. DEMONSTRATION OF MEETING REVIEW CRITERIA
I am applying for (check the one that applies):
¨ 12-month term under II.A (complete Part A below)
¨ Additional extension under II.B (complete Part B below)
PART A: Applying for an additional 12-month term under II.A
Date of application for New Access Point: ______
Is this an Anticipated Date or Completed Date? ______
Date of application for FQHC Look-Alike: ______
Is this an Anticipated Date or Completed Date? ______
PART B: Applying for an extension under II.B
Does the organization have an FQHC or FQHC Look-Alike application pending? ______
Which application is pending?______
If so, when was it submitted?______When is a reply expected?______
Has a recent FQHC Look-Alike application been denied or your health center’s FQHC application not funded (past 6 months)?______
If so, when do you plan to re-submit?______
Which application do you plan to re-submit?______
V. SIGNATURES:
President of Board of Directors:
______
Printed Name Signature Date
Executive Director/CEO:
______
Printed Name Signature Date
Chief Financial Officer:
______
Printed Name Signature Date
The above signatories of this application certify that the information provided herein is complete and accurate.