Nominate A Club

• Name*
  FirstLast
• Email*
• Phone
• Employer
• Health Care Insurance*
  South Country Health Alliance (SCHA)Blue Cross of MNBlue Cross of NDUnited Health CareFargo Public SchoolsUCareRegency Managed GroupHumanaAmerica's TPA
• Club Name*
• Club Address*
  Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code
• Club's Phone Number*
• Club Manager's Name*
• Club Manager's Email
• Club Manager's Fax
• Club's Website
• Are You A Member?*
  YesNoConsidering Membership