ALPHA Membership Application

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* 1. Provide your Name and Phone Number

First Name

Last Name

Agency

Title

City/Town

State/Province

Phone Number

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* 2. Email Address (will be used for ALPHA correspondence only) some of which will come via the mail service MailChimp.

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* 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.

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* 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)

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* 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

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* 6. Is it okay to recognize your membership in our newsletter or website as a contributor/friend of public health?

Yes

Optional Questions:

Please answer the following OPTIONAL two questions to enable ALPHA to serve its membership better.

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* 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

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* 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

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* 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.)

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* 10. Person completing this form

Name

Phone Number

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 page

If you are paying by a check, please mail it to:
ALPHA
c/o Information Insights
PO Box 83070
Fairbanks AK 99708

If you have any trouble paying online, please call Susan at 907-450-2488.