Agency Membership Contacts |
Please complete all contact information
If you are a State Agency you can add a total of 15 employees, plus one Executive Assistant to the CEO, to your official APHSA roster (16 total employees).
If you are a Local Agency you can add a total of 10 employees, plus one Executive Assistant to the CEO, to your official APHSA roster (11 total employees).
*The titles in the form are who APHSA suggests you add. If the title of the person you are adding does not match the title on the form please fill in the "Title" field with the correct title of the person you are adding.
**If the Agency Name and/or address are the same for multiple contacts please enter "see above entry" in the agency name and/or address fields.