JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
ACT 2019-2020 Membership
To apply for membership, please complete this form, then mail your check for dues to the attention of Catellia Casey, Manager of Member Services, AIDS Connecticut, 110 Bartholomew Ave, Ste 3050, Hartford, CT 06106.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Member Category
*
Membership dues are based on entire agency operating budget, not including capital or pass-through. Please select one of the following categories of membership / dues.
Full Member (> $1 million) / $300 dues
Full Member ($500,000 - $999,999) / $250 dues
Full Member (< $500,000) / $200 dues
Affiliate Member-Nonprofit Agency / $150
Affiliate Member-Individual / $25
Executive Director/Individual
*
Your answer
Agency
*
Your answer
Mailing Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Alternate Contact
Please list point of contact for AIDS CT, if not Executive Director
Your answer
Alternate Contact Email
Your answer
Designated Voter
ONLY complete this field if your agency is a FULL member.
Your answer
Membership Conditions
*
By checking this box your agency agrees to the spirit and letter of the conditions outlined in the 2019-2020 Letter of Understanding for Membership in AIDS Connecticut (ACT) and requests membership in the Coalition:
http://www.aids-ct.org/pdf/membership.pdf
I agree
Required
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Advancing CT Together.
Report Abuse
Forms
