National Health Collaborative on Violence and Abuse (NHCVA): New Member Interest Form

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Organization Name *

Organization contact info (phone, email, url, etc.) *

Organization Mission *

Applicant name *

Applicant contact info (phone, email, etc.) *

Please describe your organization's mission as it relates to Health and Violence, and why NHCVA membership is sought *

NHCVA meets by telephone conference monthly and in person, in Washington DC, yearly. Will the organization's representative be able to commit to one monthly conference call and one yearly meeting? *

Yes

Maybe

Other:

An annual membership fee of $100 is suggested, but not required, of all new NHCVA members. Is the organization able to meet this request? *

Yes

Maybe

Other:

Please enter any information or comments that might be useful. Thank you for your interest in becoming a member of NHCVA!

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