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