Become a registered member of the coalition
Register for information about upcoming events or to get more intimately involved with the coalition. This registration form was designed
to help coalition leaders manage participation efficiently and get participants involved in areas where they have demonstrated interest. Please
take a few minutes to complete this questionnaire. Make sure to hit the "Submit" button at the bottom of the page when you are done. This will ensure your inclusion on the PC3 listserv where you will receive important information about PC3 activities.
Your Information
Is this an individual membership or an organizational membership? *
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Individual/Organization name:
* We may post members on the website
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First Name *
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Last Name *
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Job Title *
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Organization
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Address
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City
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State
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Zip
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County
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Email *
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Phone
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Discipline:
Other Disciplines:
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Interested in working with the following committee(s):
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I would be willing to be a guest speaker at future coalition conferences (or other educational offering).
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Topic of Speech:
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