Application to Join
Name of your organization: *
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Type of organization (IRS designation): *
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Organization street address: *
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Organization city: *
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Organization state: *
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Organization zip code: *
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Name of official representative to coalition: *
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Title of official representative: *
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Representative's e-mail: *
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Representative's telephone number: *
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Alt. telephone number:
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Representative's street address:
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Representative's city:
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Representative's state:
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Representative's zip code:
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By checking this box, we hereby request that the above named Coalition approve our organization as a member. We have read the values and purposes of the Coalition and indicate our willingness to abide by said values and purposes by our signed statement. *
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Please describe process of authorization (e.g., board action, membership vote, etc): *
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Name of signatory: *
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Title of signatory: *
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Date: *
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