Company Name: *

Street Address: *

City *

State *

Zip Code *

Representative's Name (this representative is the partner contact, and not necessarily an individual member): *

Title or Position: *

Email Address: *

Phone Number: *

I wish to become a Coalition Partner at one of the following levels. *

Please add the name(s) and email address(es) of all employee(s) that you are registering as a TxOHC active member under your Coalition Partner membership.

	Name	Email Address
1	Name	Email Address

	Name	Email Address
1	Name	Email Address
2	Name	Email Address
3	Name	Email Address
4	Name	Email Address
5	Name	Email Address

	Name	Email Address
6	Name	Email Address
7	Name	Email Address
8	Name	Email Address
9	Name	Email Address
10	Name	Email Address

	Name	Email Address
11	Name	Email Address
12	Name	Email Address
13	Name	Email Address
14	Name	Email Address
15	Name	Email Address

	Name	Email Address
16	Name	Email Address
17	Name	Email Address
18	Name	Email Address
19	Name	Email Address
20	Name	Email Address

Please use our contribution towards the sustainability of the Coalition.

TxOHC also appreciates in-kind donations to help maintain our infrastructure and overhead cost. The fair market value of the product or service will be used towards the total partner contribution.

We also want to encourage creativity and the development of possible stakeholder initiatives. Please contact Beth Stewart at b.stewart@txohc.org to discuss creating an initiative, customizing your sponsorship package or any products or services you would like to contribute towards your sponsorship.

Coalition contributions are considered unrestricted funds, but if you wish to discuss your contribution going towards a specific program or using in-kind donations towards your contribution amount, please contact Executive Director Beth Stewart at b.stewart@txohc.org.

I am interested in discussing an in-kind donation to be used towards my total sponsorship contribution.

I wish to help sponsor a Perinatal Oral Health Project.

I wish to help sponsor an Older Adult Oral Health Project.

I wish to discuss creating an initiative or customizing my sponsorship package.

To discuss our partnership further, please contact:

at

or

Statement of Principles: (Requires Signature Below)

The Texas Oral Health Coalition, Inc. (TxOHC) is a statewide nonprofit leading efforts to achieve optimal oral health across the lifespan.

The Texas Oral Health Coalition, Inc. (TxOHC) is a statewide nonprofit leading efforts to achieve optimal oral health across the lifespan. Our members create a nonpartisan network of diverse stakeholders focused on creating viable solutions, sharing innovative information and leveraging resources for the health of all Texans. If you envision optimal health for all Texans then we would like to invite you to apply for membership and partner with our Coalition.

I, the authorized representative for the above-named organization, support in principle the Texas statewide Oral Health Coalition and choose to be part of the Coalition for the betterment of all Texans.

Electronic Signature: (Please type your First and Last Name) *

I affirm my electronic signature is the legal equivalent of my manual signature on this agreement confirming that I acknowledge and agree to the above Statement of Principles.

*