Membership Application

Thank you for participation with the Coalition for a Tobacco Free Hawai`i. Over the course of the last two-years, the Coalition has been moving forward with a new organizational structure. One of our goals is to expand our grassroots and grow our membership. We invite you to join as a member for the year 2006-2007. Your participation and cooperative partnership is vital to sustaining our organization.

To read our membership brochure first, click here.

Type of Membership	Sustaining Organization $100 per year Sustaining Individual $50 per year Associate Organization $50 per year Associate Individual $25 per year
First Name
Last Name
Organization
Position
Mailing Address
City
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Zip	-
Business Phone
Fax
Email
In order to match you to your legislative district for policy and advocacy purposes we need your home address.
(Home Address) Street
City
State	Select One... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Zip	-
Home Phone
Cell
Alt Email
Please give us a brief overview of your business/organization to be included in our membership directory. This information will be used in our public directory.
Overview
Included in our Directory?	Yes   No
Are you interested in serving on a workgroup?	Yes   No
If yes, please check group	Policy Membership Fund Development Prevention Cessation Communication, Evaluation, Systems (See Member Brochure for Description) If you are submitting the application as an organization, please list your primary representative above and the alternate below:
Last Name
First Name
Please tell us what would be beneficial to you as a member as resource