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* 1. Please check the range in which the coalition's budget falls. The corresponding annual dues amount follows each answer.

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* 2. The ANOHC board recognizes that many state coalitions are facing particular funding challenges this year. If those challenges prevent your coalition from paying the dues amount associated with your budget, please explain your situation and indicate the maximum dues amount that is feasible for you in the box below. In order to cover our fundamental expenses, we ask this be a minimum of $100 and that you only request an accommodation if absolutely necessary. ANOHC needs your financial support more than ever to serve as an effective advocate for the issues critical to its members, and to provide valuable connections, guidance, and resources to members in the coming year. A member of the ANOHC board will reach out to you regarding your request.

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* 3. Please provide your coalition's information.

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* 4. Representative contact information:

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* 5. Coalition representative to subscribe to the ANOHC listserv:

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* 6. Additional coalition representative to subscribe to the ANOHC listserv:

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* 7. Around what topics or issues would you like to receive guidance from ANOHC in the coming year (for example, through webinars, discussions at the annual meeting, etc.)?

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* 8. I certify that the information listed above is accurate to the best of my knowledge, and that I am authorized to apply for ANOHC membership on behalf of the coalition named above.

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