Form 2

QHIN Application

Part I - Basic Applicant Information

Please complete the following fields.

"*" indicates required fields

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Record Type ID

Submission ID*

Applicant’s Legal Name*

List all other names under which the applicant does business (Doing Business As, Alias, Trademarks, etc.)

Address of Principle Place of Business*

Website*

State/Jurisdiction Where Organized*

Legal Structure*

Executive POC Name*

Executive POC Phone*

Executive POC Email*

Technical/Testing POC Name*

Technical/Testing POC Phone*

Technical/Testing POC Email*

Legal POC Name*

Legal POC Phone*

Legal POC Email*

Finance POC Name*

Finance POC Phone*

Finance POC Email*

CISO POC Name*

CISO POC Phone*

CISO POC Email*

Parent Legal Name

(If Applicant is a wholly-owned subsidiary and will be relying on Parent’s Current Network to demonstrate Historic Experience)

If you have a question at any time during the application process please feel free to contact the RCE team. We'll be happy to assist you.