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Affiliation Application
Non- A2A Affiliate Use this form if you do not currently receive A2A funding through the Alliance
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* Indicates required question
Email
*
Your email
Name of Organization
*
Your answer
Name of Organization (as you would like it to appear on our website and affiliation certificate)
*
Your answer
Physical Address of Organization
*
Your answer
Mailing Address of Organization (if different from above)
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
County Organization is located in
*
Your answer
Name of Executive Director and Birth Day (mo/day)
*
Your answer
Executive Director Email
*
Your answer
Executive Director Cell Phone
Your answer
Organization Phone
*
Your answer
Name of Board Chair/President
*
Your answer
Board Chair/President Email
Your answer
Client Website
*
Your answer
Donor Website
Your answer
Other Affiliations
*
No other affiliations
Heartbeat International
CareNet
Christian Leadership Alliance
ECFA
Life Matters Worldwide
NIFLA
Other
Required
Please list other affiliations
Your answer
Medical Center/Clinic
*
Yes
No (if you answered no please proceed to next section)
Required
Name of Medical Director
Your answer
Name of Nurse Manager
Your answer
Nurse Manager Email
Your answer
Which medical services do you currently provide?
Ultrasound
STI/STD Testing
Prenatal Care
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