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First Name	*
Last Name	*
Position as Facility	*
Facility Name	*
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Facility Phone Number	*
Facility-wide username and password (to be used by all employees at your facility)	*
Email	*
Username	*
Password	*
Retype Password	*

Indiana Health Care Association
One North Capitol, Suite 100
Indianapolis, IN 46204
Phone: 800-466-IHCA Fax: 877-298-3749

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