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Membership Application
Type of Membership:
Full
Associate
Name of Organization:
Address:
City:
State:
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District Of Columbia
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Ohio
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Texas
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Virginia
Washington
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Zip/Postal Code:
County:
ALAMEDA
ALPINE
AMADOR
BUTTE
CALAVERAS
COLUSA
CONTRA COSTA
DEL NORTE
EL DORADO
FRESNO
GLENN
HUMBOLDT
IMPERIAL
INYO
KERN
KINGS
LAKE
LASSEN
LOS ANGELES
MADERA
MARIN
MARIPOSA
MENDOCINO
MERCED
MODOC
MONO
MONTEREY
NAPA
NEVADA
ORANGE
PLACER
PLUMAS
RIVERSIDE
SACRAMENTO
SAN BENITO
SAN BERNARDINO
SAN DIEGO
SAN FRANCISCO
SAN JOAQUIN
SAN LUIS OBISPO
SAN MATEO
SANTA BARBARA
SANTA CLARA
SANTA CRUZ
SHASTA
SIERRA
SISKIYOU
SOLANO
SONOMA
STANISLAUS
SUTTER
TEHAMA
TRINITY
TULARE
TUOLUMNE
VENTURA
YOLO
YUBA
Phone:
Fax:
Website:
Organization Type:
Select One...
Academic Institution
Community-Based Organization
Community health Center
Corrections Institution
County Public Health Department
Hospital or Outpatient Clinic
Laboratory
Local viral Hepatitis Task Force
Other Governmental Organization
Pharmacy
Research Center
State Public Health Department
Veteran's Administration Hospital/Clinic
Other
Population / Risk Group:
Select One...
Asian & Pacific Islanders
Blood transfusion / organ recipients
Current and former injection drug users
Foreign-born individuals
Gay men/men who have sex with men
People living with hepatitis B
People living with hepatitis C
People who have been formerly incarcerated
People with hemophilia
People with unknown risk factors
Veterans
Other
Service Provision:
Select One...
Community Advocacy Organization
County Public Health Services
Health Education / Training
HIV Prevention/ Treatment/ Care
Mental Health
Perinatal Hepatitis B
Pharmacy
Primary Care/Managed Care/Medical Specialist (HIV, Hepatology, GI, etc.)
Prison / Jail / Re-entry Health
Researcher
State Public Health Services
Substance Abuse
Syringe Exchange
Viral Hepatitis Prevention/ Services
Other
Region Size:
Select One...
Urban Metropolitan: area with a population greater than 100,000
Urban non-metropolitan: area with a population between 2,500 and 100,000
Rural: area with a population less than 2,500
Description of Organization’s Mission/ Goals Relevant to Viral Hepatitis:
Voting Member:
Title:
Email:
Representative 2:
Title:
Email: