CSHCN Industrial Affiliates Program
Members Only Area

This form may be used by current members of the CSHCN Industrial Affiliates Program who wish to request access to the Members Only Area. Member status will be verified before access is granted.

Contact Information


Member Group:

If Member Group is Other, enter organization name:

Business Phone Number (with area code):

E-mail Address:

Username and Password

Please enter a username and password that will be used to access the Members Only Area. The password must be at least 4 characters in length and no longer than 12 characters. Record this username and password for future reference.


Password: Confirm Password:

Comments or Questions


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