Question Title

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

Question Title

* 2. The ANOHC board recognizes that many state coalitions are facing particular funding challenges. 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.

Question Title

* 3. How will you pay for your 2020 coalition membership in ANOHC?

Question Title

* 4. Please provide your coalition's information.

Question Title

* 5. Representative contact information:

Question Title

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

Question Title

* 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.)?

Question Title

* 8. ANOHC members who have joined or renewed, as well as paid their 2020 dues, are invited to attend the 2020 ANOHC Annual Meeting and Annual Dinner. These events will be held this year in conjunction with the National Oral Health Conference in San Diego, CA. Each coalition may send two representatives to the meeting and to the dinner. For each event, please indicate how many people from your coalition will be attending, along with their contact information. If you do not know yet which individuals will attend, simply indicate the number of people.

Question Title

* 9. 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.

0 of 9 answered
 

T