ACT 2018-2019 Membership
To apply for membership, please complete this form, then mail your check for dues to the attention of Catellia Casey, Manager of Member Services, AIDS Connecticut, 110 Bartholomew Ave, Ste 3050, Hartford, CT 06106.
Member Category *
Membership dues are based on entire agency operating budget, not including capital or pass-through. Please select one of the following categories of membership / dues.
Executive Director/Individual *
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Agency *
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Mailing Address *
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City *
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State *
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Zip *
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Phone *
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Email *
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Alternate Contact
Please list point of contact for AIDS CT, if not Executive Director
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Alternate Contact Email
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Designated Voter
ONLY complete this field if your agency is a FULL member.
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Membership Conditions *
By checking this box your agency agrees to the spirit and letter of the conditions outlined in the 2018-2019 Letter of Understanding for Membership in AIDS Connecticut (ACT) and requests membership in the Coalition: http://www.aids-ct.org/pdf/membership.pdf
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