US COPD Coalition: Potential/Current Membership Information Survey

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1. Please provide us with the following information about your organization:

Please provide us with the following information about your organization:   Name of Organization
Website URL (type "None" if none)

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2. Please provide your organization's contact information, including the primary contact person's name, phone number, and e-mail address.

Please provide your organization's contact information, including the primary contact person's name, phone number, and e-mail address.   First and Last Name:
Title:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
Country:
Email Address:
Phone Number:

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3. Please specify your organization's state of incorporation in the first drop-down menu. And please specify your organization's outreach focus (local, state, regional, or nationwide) in the second drop-down menu.

	State/Territory of Incorporation	Outreach Focus
Please select one from each menu:	Not Applicable/OtherAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Please specify your organization's state of incorporation in the first drop-down menu. And please specify your organization's outreach focus (local, state, regional, or nationwide) in the second drop-down menu.   Please select one from each menu:   State/Territory of Incorporation	Local/Metro AreaStatewideRegionalNationalOther Outreach Focus

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4. What best describes the classification of your organization?

What best describes the classification of your organization?   State Coalition Patient Advocacy Organization Professional Society

Other (please specify)

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5. What best describes the legal status of your organization?

What best describes the legal status of your organization?   501(c)(3) IRS Charitable Organization Other Not-for-profit Organization For-profit Organization

Other (please specify):

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6. How many individuals are members/constituents of your organization? This can include number of registered individuals, distribution lists, etc. (Please use a whole number. Do not include commas, periods, or any other signs. For example: type 1000 instead of 1,000.)

How many individuals are members/constituents of your organization? This can include number of registered individuals, distribution lists, etc. (Please use a whole number. Do not include commas, periods, or any other signs. For example: type 1000 instead of 1,000.)

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7. Does your organization file an annual 990 form?

Does your organization file an annual 990 form?   Yes No

If you answered "Yes" please specify how a copy can be obtained:

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8. Does your organization have by laws?

Does your organization have by laws?   Yes No

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9. Does your organization have a mission statement? If yes, then please provide it in the space below.

Does your organization have a mission statement? If yes, then please provide it in the space below.   Yes No

Mission Statement

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10. Please take the time to tell us about your organization's programs. You can also use this comment box to state any additional information about your organization, if you choose.

Please take the time to tell us about your organization's programs. You can also use this comment box to state any additional information about your organization, if you choose.

11. Please tell us what you would like to see the US COPD Coalition do in the coming year.

We thank you in advance for filling out this form!

**Once submitted your application will be forwarded to the Board of Directors and you will be contacted with a response. For more information on joining the Coalition please contact Jamie Lamson at 202-445-4009.

Please tell us what you would like to see the US COPD Coalition do in the coming year. We thank you in advance for filling out this form! **Once submitted your application will be forwarded to the Board of Directors and you will be contacted with a response. For more information on joining the Coalition please contact Jamie Lamson at 202-445-4009.