Florida Public Health and Healthcare Preparedness Capability Team Membership Application

Thank you for your interest in serving as a member of one of Florida's Public Health & Healthcare Preparedness (PHHP) Capability Teams. Please provide complete information in the application below. Once you have submitted your information, a member of the PHHP Strategic Planning Team will contact you regarding further steps. We look forward to working with you.

Please fully complete the following questions to provide your personal information.

* 1. How would you like to be addressed?

* 2. Please enter your first name:

* 3. Please enter your last name:

* 4. List any credentials you have. (i.e. RN, MPH, etc)

* 5. Business Mailing Street Address:

* 6. City:

* 7. State:

* 8. Zip Code:

* 9. Email address:

* 10. Phone Number (with area code):

* 11. Please select the type of organization or business you represent or are employed by from the list below:

* 12. Enter the name of the agency or organization where you are employed:

* 13. Position Title: