Affiliate OrganizationGeneral Information "*" indicates required fields Affiliate Leader Name* First Last Point of Contact Name (if different from above) First Last Name of Organization*Number of Members (Approximate)*Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County within your State*Point of Contact Email* Point of Contact Phone*General Information About Your OrganizationSign me up! Moms for America Newsletter How did you hear about us?Spam Catcher: 16 + 11 =*CAPTCHANameThis field is for validation purposes and should be left unchanged.