Join Our Campaign
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1. Sign On to HCFANY
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1
. Please indicate if you are acting as an:
Please indicate if you are acting as an:
Individual or Small business (not affiliated with an organization)
Organization
*
2
. Please choose ONE:
Please choose ONE:
Yes! We endorse HCFANY's 10 Standards for Quality, Affordable Health Care for All. Please sign me or my organization (as indicated above) up to be a HCFANY a campaign member (open to all organizations who serve, represent, or advocate for consumers)
NO - I or my organization cannot join HCFANY right now, but please sign me up for your email list so that I can be kept informed of campaign activities.
*
3
. For individuals/organizations that are signing on, please fill in all fields. If you only wish to sign on to HCFANY's mailing list, you only need to fill in your email address.
For individuals/organizations that are signing on, please fill in all fields. If you only wish to sign on to HCFANY's mailing list, you only need to fill in your email address.
Name:
Company:
Address:
Address 2:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
Email Address:
Phone Number:
4
. Please indicate the scope of your organization
Please indicate the scope of your organization
Statewide
Regional
Local
5
. Please indicate if your organization is
Please indicate if your organization is
a Coalition
a trade/professional group
other
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