COMMISSION ON HIV MEMBER APPLICATION

Introduction

Thank you for your interest in becoming a member on the Commission on HIV. Please complete this Membership Application (Application) in its entirety and submit electronically where prompted. This Application will take approximately 10-12 minutes to complete. For questions or assistance in completing this Application, please contact Commission staff at hivcomm@lachiv.org or at 213.738.2816.

Once the Application is submitted, Commission staff will review the Application for completeness and will notify you regarding next steps.

A paper version of this Application is available by printing the Application where prompted or by contacting Commission staff to have an Application sent to you.

Again, If you would like assistance in completing the Application or have questions concerning the membership application process, please contact Commission staff at hivcomm@lachiv.org or at 213.738.2816. For more information regarding the Commission, please visit our website at https://hiv.lacounty.gov.

*Questions requiring responses are preceded by an asterisk.

Question Title

* 1. Are you applying as a NEW or RETURNING member?

NEW

RETURNING

Question Title

* 2. Contact Information

Name and Pronoun (For example: "John Smith, he/him/his") *

Do you work for an agency/organization? If yes, please state agency/org name and if not, please indicate "N/A" for not applicable. *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Primary Email Address *

Primary Phone Number *

Question Title

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. Not required; suggested for applicants representing agencies/organizations

Yes

Recommending individual/organization:

COMMISSION ON HIV MEMBER APPLICATION

Introduction

Question Title

* 1. Are you applying as a NEW or RETURNING member?

Question Title

* 2. Contact Information

Question Title

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. **Not required; suggested for applicants representing agencies/organizations**

* 3. Were you recommended by an individual or organization? If so, please state the name of the recommending entity. Not required; suggested for applicants representing agencies/organizations