alzfdn.org - membership application form

Membership: *

Member

Associate Member

Second Wind Dreams Member

Name of Organization: *

Address:

City:

State/Province:

Zip Code: *

Day Telephone:
(use xxx-xxx-xxxx format) *

Fax Number:
(use xxx-xxx-xxxx format) *

Website Address: *

Executive Director: *

Contact Person
(for communication from AFA): *

Email Address: *

Other Key Personnel:

	Name	Title
1.	Name	Title
2.	Name	Title
3.	Name	Title

Type of Organization/Company: *

Nonprofit Organization

For-profit Organization/Company

Federal Tax ID Number:

Organization Activities: *

Geographic Area Served:

Number of Employees:

Number of Volunteers:

Annual Budget:

Percentage of Revenues Spent on:

	Management
	Fundraising
	Programs and Services

0/100 points

Select Advisory Board (For Member Organizations Only): *

Public Relations	Development
Advocacy	Social Services

What are the immediate needs facing your organization? *

What are the long term needs facing your organization? *

What additional programs/services would you like to offer in the future? *

For information about annual dues, please contact AFA at 866.AFA.8484.

To apply for membership, please complete this application
and click "submit" at the end of the form or print out this form
and submit the completed application via fax or regular mail.
In addition, please send AFA your dues payment and a copy
of your latest IRS Form 990 and proof of 501(c)(3) status,
as well as newsletters and brochures about your organization.

Alzheimer's Foundation of America
322 Eighth Ave., 7th floor
New York, NY 10001

Email: info@alzfdn.org
Fax: 646.638.1546

Hotline	Resource Directories
Home Health Aides	Counseling
Support Groups	Nursing Home
Adult Day Services	Respite Care
Assisted Living	Conferences/Workshops
ID/Safety Programs	Professional Training
Educational Materials	Newsletter
Other Other