PPA MEMBERSHIP FORM
Prevention Professionals of Arkansas
2026-2027 Membership Year
MEMBERSHIP RATES
Individual: $25 Student: $20
Organization: $100 (up to 5 members)
Student documentation required
MEMBERSHIP INFORMATION
Is this a NEW membership?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about PPA?
Online
Printed Material
Conference/Event
Existing Member
If referred by a current member, please provide their name:
What type of membership?
Sponsor Organization
Individual
Student
MEMBER INFORMATION
Member's Name:
First Name
Middle Initial
Last Name
Agency:
Title:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address: (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone #:
Format: (000) 000-0000.
Contact Email Address:
example@example.com
Email address is necessary to receive quarterly newsletter, legislative alerts, and updates on training and workshop opportunities.
SPONSOR ORGANIZATION INFORMATION
Name of Sponsor Organization:
List each member and his/her E-mail. Complete a separate membership form for each member (if applicable):
1. Primary Contact:
2.
3.
4.
5.
MEMBERSHIP APPLICATION & PAYMENT
Please complete and submit the membership application electronically.
Membership dues may be paid by check, payable to PPA, and mailed to:
PPA Membership, Prevention Professionals of Arkansas
P.O. Box 11235, Fayetteville, AR 72703
FOR PPA USE ONLY
Amount received:
Cash
Check #
PPA follows the federal fiscal year of Oct 1-Sept 30 for the purpose of dues and other business.
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