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.

Question Title

* 1. Please choose State or Local Agency

Question Title

* 2. CEO/Secretary/Commissioner

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 3. Assistant to the CEO/Secretary/Commissioner - this should be the main point of contact for the CEO/Secretary/Commissioner's office.

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 4. Deputy CEO/Secretary/Commissioner

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 5. Assistant to the Deputy CEO/Secretary/Commissioner - this should be the main point of contact for the Deputy CEO/Secretary/Commissioner's office.

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 6. Chief Information Officer (CIO)

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 7. Attorney General/General Council/Lead attorney for the agency

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 8. ICPC Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 9. SNAP Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 10. Child Care Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 11. Performance Management/Quality Control Manager

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 12. Child Welfare Director/Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 13. TANF Director/Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 14. Organizational Development/Staff Development/Training Director/Administrator

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 15. Other

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 16. Other

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone

Question Title

* 17. Other

First Name

Last Name

Agency Name

Title

Address

Address 2

City

State

Zip

Telephone