Survey - ALA-MP LLB Survey - American Lung Association of the Mountain Pacific

Fighting for Air Online

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1. Contact Information:

Name:

Title	First Required	Last Required	Suffix

Email: Required

Address Line 1: Required

Address Line 2 (Optional):

City/State/ZIP:

City Required	State Required	ZIP Required

Phone Number: Required

Employer:

Gender:

If you respond and have not already registered, you will receive periodic updates and communications from American Lung Association.

Yes, I would like to receive postal mail from American Lung Association

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___________________________________

Question - Required - 2. Number of years served on the Leadership Council?

Question - Required - 3. Age:

Question - Required - 4. Race/Ethnicity (Enter only one category):

Question - Required - 5. Industry (Enter only one category):

Question - Required - 6. Area of Expertise (Check all that apply)
Please make at least 1 selection from the choices below.

Question - Required - 7. Relationships (Check all that apply):
Please make at least 1 selection from the choices below.

	Access to Revenue Sources
	Access to Healthcare Community
	Access to Corporate Leaders
	Access to Community Leaders
	Other

If you have any questions about the survey or the form, feel free to call Linda Kadekawa at 206-512-3284 or email her at Linda.Kadekawa@Lung.org.