Affiliate Application

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Please complete and submit the application to become an MHN Affiliate.

Organization Name *

Date *

Contact Persion *

Title *

Email Address *

Phone *

Fax

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Choose the options that best describe your organization / company *InternationalNationalStateLocalHospital/Clinic/Physician OfficeHealth AssociationFraternal OrganizationGovernment entity (Federal/State/Local)Religious OrganizationActivist Organization

Is your Organization Health Related?My Organization is Health Related.

The applicant is a division or chapter of a broader organization.

Please explain the relationship to the broader organization.

Describe the purpose and goals of the applicant. *

When was the applicant founded? *

Membership Organization?Is the applicant a membership organization?

Who is eligible to be a member? *

Number of Members

Describe the population our programs serve. *

How is the applicant registered with the Internal Revenue Service (if applicable)?501(c)(3)501(c)(4)501(c)(6)

Registration Number

info@menshealthnetwork.org

Men's Health Network
P.O. Box 75972
Washington, D.C. 20013

202-543-MHN-1 (6461) ext. 101

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