Coalition Member Application | Greater Sacramento Smoke & Tobacco Free Coalition

Name(Required)

Organization

Preferred Mailing Address(Required)

City of Employment

Zip of Employment

City of Residence**

Zip of Residence**

Email(Required)

Phone

Language(s)

Priority Populations Other(Required)

What other priority populations do you serve?

Constituencies Other(Required)

What other constituency(ies) populations do you serve?

Ethnicity/Race Other(Required)

What is your ethnicity/race?

*By filling out this application, I agree to become a member of the Greater Sacramento Smoke & Tobacco Free Coalition (GSSTFC). I have read the Coalition Bylaws, and I understand the roles and responsibilities of membership. I agree to have my name and professional contact information listed in the Coalition roster. I certify that I do not accept Tobacco Industry (TI) or electronic smoking device funding or participate in TI or electronic smoking device supported events or activities.
**Residence city/zip code may be used when planning for public comment at city council meetings, etc. to show constituency representation.