Company Name: *

Street Address: *

City *

State *

Zip Code *

Representative's Name: *

Title or Position: *

Email Address: *

Phone Number: *

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

Please add the names and email addresses of your employees that you are including in your Coalition Partner membership. Upon receipt of this information, we will contact these individuals to complete the membership process.

	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

	Name	Email Address
21	Name	Email Address
22	Name	Email Address
23	Name	Email Address
24	Name	Email Address
25	Name	Email Address

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.

Please use our contribution toward the sustainability of the Coalition.

I am interested in making 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.

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.

TxOHC is the primary organization in Texas that provides a nonpartisan forum which allows a diverse network of stakeholders to collaborate and create innovative and viable solutions to improve oral health for 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.

*