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TB Elimination Alliance Membership Interest Form

Thank you for your interest in the TB Elimination Alliance. Membership is reviewed quarterly in April, August and December. After your form has been reviewed, you will be contacted with next steps. Please contact tea@aapcho.org if you have any questions or concerns. 
1.Organization/Coalition(Required.)
2.Contact Person(Required.)
3.Secondary Contact Person(Required.)
4.Organizational Information: Please check all categories that best describe your organization.(Required.)
5.Organizational Structure(Required.)
6.Month/Year Founded(Required.)
7.Region/State/County/City Represented(Required.)
8.Number of staff/members/volunteers in your organization (please specify)(Required.)
9.Targeted populations (please specify)(Required.)
10.Organizational Mission Statement(Required.)
11.Organizational Interest (Needs) in TB Elimination Alliance Membership (please specify)(Required.)
12.Organizational Activities: Briefly describe the activities of your organization (or attach descriptive material)(Required.)
13.Does your organization have any of the following community based LTBI/TB specific activities/programs?
14.Are there any LTBI/TB education/outreach materials created by your organization you would like to share?
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15.Any additional attachments you would like to share?
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16.Any additional attachments you would like to share?
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Current Progress,
0 of 16 answered