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.

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1. Contact Information: (Required.)

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2. Current Place of Employment (if applicable):

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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:

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: (Required.)

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6. I prefer to receive written correspondence at:

 (Required.)

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7. I prefer to receive phone calls and messages at: (Required.)

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