ALPHA Membership Application Question Title * 1. Provide your Name and Phone Number First Name Last Name Agency Title City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Phone Number OK Question Title * 2. Email Address (will be used for ALPHA correspondence only) some of which will come via the mail service MailChimp. OK Question Title * 3. Level of Membership Individual One Year $55 Student One Year $20 Retired One Year $20 Individual Two Years $110 Student Two Years $40 Retired Two Years $40 Organizational Membership ($125-$275 based on annual budget) The following question will determine your fee. OK Question Title * 4. Organizational Membership. If you checked organizational membership in the previous question, what is your organization's annual budget? Less than $250,000 ($125 membership fee) $250,000 to $500,000 ($175 membership fee) $500,001 to $999,999 ($225 membership fee) $1,000,000 or more ($275 membership fee) OK Question Title * 5. Additional Contribution: Yes, I'd like to make an additional tax deductible contribution to ALPHA. These funds may be used to supplement travel scholarships for members to attend the summit, mini-grants to communities, or to support ALPHA's mission. Note: Add this to the cart when paying your dues. $25 $45 $50 $75 $100 Other OK Question Title * 6. Is it okay to recognize your membership in our newsletter or website as a contributor/friend of public health? Yes No OK Optional Questions:Please answer the following OPTIONAL two questions to enable ALPHA to serve its membership better. OK Question Title * 7. ALPHA is an affiliate of the American Public Health Association (APHA). Are you already a member of APHA? Yes, I am a current American Public Health Association member Please send me information on joining APHA Don't send me any information at this time OK Question Title * 8. I am interested in being involved with ALPHA (Check all that apply) Health Summit: helping plan and coordinate the Summit program and presentations Education: creating educational content for the ALPHA newsletter and website Awards: soliciting and selecting the ALPHA award recipients Membership/Public Relations: enhancing ALPHA membership recruitment, retention and brand in Alaska Mentoring: orienting new members to ALPHA OK Question Title * 9. How will you pay your dues? Check Credit Card (You will be redirected to a secure PayPal page to process your membership payment. You do not need a PayPal account to pay by credit card.) OK Question Title * 10. Person completing this form Name Phone Number OK Thank you for choosing to become a new member of ALPHA or for renewing your ALPHA membership. Payment is accepted by credit card, PayPal, or check. You do NOT need to have a PayPal account. Just look for the link that says "Don't Have a PayPal Account?" on the payment pageIf you are paying by a check, please mail it to:ALPHA c/o Information InsightsPO Box 83070Fairbanks AK 99708If you have any trouble paying online, please call Susan at 907-450-2488. OK DONE