Membership Application Form (*)
Please complete the following form for membership consideration in the LIFE Ambassadors of Texas. For required responses that are not applicable to your organization, submit the text "N/A".
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Name of Organization *
Physical Address *
Mailing Address *
Organization Main Phone Number *
Organization Client Website *
Organization Donor Website (if applicable)
Organization Executive Director/ CEO *
Executive Director/ CEO email *
Executive Director/ CEO cell phone *
Chairman/President of Board of Directors *
Board Chair/President email *
Affiliations (check all that apply) *
Required
Medical Center/ Clinic *
Name of Medical Director
Which services do you currently provide? (Check all that apply.) *
Required
Which services would you like more information about? (Check all that apply.) *
Required
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