Membership Application – Teen scholarship Membership DuesAnnual membership dues are determined by organization type & affiliation and will be prorated depending on month membership is activated. Once the application is completed and returned, a Membership Coordinator will provide an official payment form.This field is hidden when viewing the formMEMBERSHIP TYPE/DUES(Required)Individual/Professional, $25 (discounted from $50)INDIVIDUAL INFORMATIONName(Required) First Last Address(Required) Street City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Main Phone #(Required)Personal Email(Required) College/UniversityThis field is hidden when viewing the formSERVICES PROVIDED (Check all that apply) Adult Day Program Alzheimer's-Specific Products AFA Memory Screening Site Caregiver Support Case Management Companion Services Dementia Care Elder Law Home Health Care Information Referral Center Long-Term Care Multilingual Services/Info Nursing Services Respite Care Religious/Cultural Services Support Services Senior Center Young-Onset Programs Other If other, please specify(Required)This field is hidden when viewing the formUse the following checklist to ensure that you have completed and compiled everything to submit for AFA membership. Copy of your organization's latest IRS form 990 (Pages 1-2 only) Letter of 501(c)(3) status This field is hidden when viewing the formFile Upload Drop files here or Select files Max. file size: 2 GB. This field is hidden when viewing the formReturn completed application and supporting documentation via email to: membership@alzfdn.orgQuestions? Give us a call at 866-232-8484 and ask to speak with a National Membership Coordinator today!Individual Membership Dues(Required) Price: Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Billing Address(Required) Same as Mailing Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Total Δ Please share this page with your loved ones and colleagues!