Report Contact Information for Your Affiliate Report Contact Information for Your Affiliate Use this form to let us know how your affiliate and affiliate leaders can be contacted. Affiliate Name*Your Name*Your Email* What information do you wish to report? Affiliate E-mail Address Affiliate website Affiliate Mailing Address Main Public Contacts Leadership Contacts Main Affiliate Email Address Affiliate Website Affiliate Mailing AddressPlease enter the official mailing address for your affiliate here. Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Main Public ContactsPlease enter the main contacts for your affiliate. You may provide an email address, a phone number, or both. This information will be made public on the NAMI Georgia website. Click the '+' icon next to entry to add another row.NamePhoneEmail Affiliate Leadership ContactsPlease enter contact information to add one or more people in your affiliate who may need to communicate with NAMI Georgia staff. (i.e. President, membership coordinator, website manager, namiwalks coordinator). They don't necessarily have to be an official representative of the affiliate. Click the '+' sign on the right of an entry to add another person.NameRoleEmailPhone Please put any other important details here. Thank you!Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.