U.S. COPD Coalition Membership Application

Tell us about your organization

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* 1. Please provide us with the following information about your organization

Name of Organization

Website URL (Type "None" if none)

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* 2. Please provide your organization's contact information, including primary contact person's name, phone number and email.

First and Last Name:

Title:

Address:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Phone number:

Email address:

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* 3. In what state is your organization incorporated?

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* 4. How would you describe your organization's outreach focus?

Local/Metro area

Statewide

Regional

National

Other (please specify)

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* 5. What best describes the classification of your organization?

State Coalition

Patient Advocacy Organization

Professional Society

Other (please specify)

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* 6. What best describes the legal status of your organization?

501(c)(3) IRS Charitable Organization

Other Not-for-Profit Organization

For Profit Organization

Other (please specify)

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* 7. Does your organization have a mission statement?

If "Yes", please provide it in the space below

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* 8. Please tell us about your organization's programs. You may also use this space to provide any additional information about your organization.

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* 9. I am authorized to complete this application to become a member of the U.S. COPD Coalition on behalf of my organization.

Thank you for filling out this membership application! Once you complete the application, it will be forwarded to the USCC Board of Directors. If you have any questions, please contact us at ksiegel@uscopdcoaliton.org.