Application for Membership

Contact Information

To help us process your membership application, please provide all of the information requested. Enter N/A (not applicable) where appropriate. If you need assistance in filling out this application, please contact the planning council support office at 410-396-1646.

Question Title

* 1. Contact Information:

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Email Address:

Phone Number:

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* 2. Current Place of Employment (if applicable):

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number:

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* 3. Information can be sent via email at any time to the Planning Council support office at Dwaynet.smith@baltimorecity.gov

If applicable, please provide your preferred email below:

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* 4. Please select your county of residence and/or employment from the list below:

Anne Arundel County

Baltimore City

Baltimore County

Carroll County

Harford County

Howard County

Queen Anne's County

Other (please specify)

Please be aware that the Greater Baltimore HIV Health Services Planning Council (planning council) is a public body. The planning council will be contacting you via mail, e-mail and/or telephone. Please tell us how you prefer to be contacted:

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* 5. Preferred method of contact:

Postal Mail

Telephone

E-mail

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* 6. I prefer to receive written correspondence at:

Home

Work

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* 7. I prefer to receive phone calls and messages at:

Home

Work

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Question Title

* 1. Contact Information:

Question Title

* 2. Current Place of Employment (if applicable):

Question Title

* 3. Information can be sent via email at any time to the Planning Council support office at Dwaynet.smith@baltimorecity.govIf applicable, please provide your preferred email below:

Question Title

* 4. Please select your county of residence and/or employment from the list below:

Question Title

* 5. Preferred method of contact:

Question Title

* 6. I prefer to receive written correspondence at:

Question Title

* 7. I prefer to receive phone calls and messages at:

* 3. Information can be sent via email at any time to the Planning Council support office at Dwaynet.smith@baltimorecity.gov

If applicable, please provide your preferred email below: