Membership Checkout Membership Level change You have selected the Screening Site Account membership level. Account Information Already have an account? Log in here Username Username cannot be changed. It is suggested that the Username be the Organzation Name Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK Membership Information Fields below are required Organization Name Contact Name Title Address Address 2 City State/Province/Territory - choose state - Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam GU Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa \ Canada \ Europe \ Middle East Armed Forces America (except Canada) Armed Forces Pacific Other Zip Code Country - choose country - Canada Puerto Rico United States Daytime Telephone Organization Type * Adult Day Programs Alzheimer's Specific Organization Assisted Living Facility Community Health Clinic Doctor's Office Government Office Home Care Provider Hospital House of Worship Library Pharmacy or Drug Store Research Clinic Senior Center Supermarket or Convenience Store Other Specify Organization Type Specify Service Provided Is your organization part of AFA’s Membership Network? Yes No Requested Information AFA Membership Dementia Care Professionals of America, AFA’s training, qualification and membership division Excellence in Care (national standards of dementia care) program AFA’s free magazine for caregivers, AFA Care Quarterly How did your organzation hear about the National Memory Screening Program? 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Membership Checkout Membership Level change You have selected the Screening Site Account membership level. Account Information Already have an account? Log in here Username Username cannot be changed. It is suggested that the Username be the Organzation Name Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK Membership Information Fields below are required Organization Name Contact Name Title Address Address 2 City State/Province/Territory - choose state - Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam GU Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa \ Canada \ Europe \ Middle East Armed Forces America (except Canada) Armed Forces Pacific Other Zip Code Country - choose country - Canada Puerto Rico United States Daytime Telephone Organization Type * Adult Day Programs Alzheimer's Specific Organization Assisted Living Facility Community Health Clinic Doctor's Office Government Office Home Care Provider Hospital House of Worship Library Pharmacy or Drug Store Research Clinic Senior Center Supermarket or Convenience Store Other Specify Organization Type Specify Service Provided Is your organization part of AFA’s Membership Network? Yes No Requested Information AFA Membership Dementia Care Professionals of America, AFA’s training, qualification and membership division Excellence in Care (national standards of dementia care) program AFA’s free magazine for caregivers, AFA Care Quarterly How did your organzation hear about the National Memory Screening Program? Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone Payment Information We Accept Visa, Mastercard, American Express and Discover Card Number Expiration Date 01 02 03 04 05 06 07 08 09 10 11 12 / 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 Security Code (CVC) (what's this?) 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