Support Statewide Ohio Asian American Health Coalition

Support Statewide Ohio Asian American Health Coalition

Organization member – $80/-

or

Individual Member   –  $20/-

Thank you for you Support

Please complete this application and send

Organization member – $80/-

Name of the Organization __________________________
Contact Person’s Name ____________________________
Address, City, State, Zip   ___________________________
Telephone: Business:   _________________  Cell Phone_______________
e-mail address_____________________________________

Individual Member   –  $20/-

Name of the person           __________________________
Address, City, State, Zip___________________________
Telephone # Personal ________________
Office       ________________
Cell Phone_______________
e-mail address: _______________________________________
Thank you for you Support
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