Colorado Medical Group Management Association

Corporate Affiliate Reference Form

Applicant First Name
Applicant Last Name
Organization Organization applying for Corporate Affiliate membership

Reference First Name
Reference Last Name
Organization Do not abbreviate - please provide complete formal name of your organization.
Phone
E-mail
Length of relationship with applicant
Services and/or products used from the applicant:
Items purchased from applicant:
Quality of customer service: (Poor 1 2 3 4 5 Excellent)
Comments:
Please check to indicate signature below and enter today's date, then press the Submit button. Thank you!

AGREED - Check here to signify signature. Today's Date

Colorado MGMA Office, 90 Madison Street, Suite 403, Denver, CO 80206
303-756-8380 fax 303-759-8861 e-mail cmgma@conferenceoffice.com