The AFA LGBT Referral Network Application
Primary Business Location
* A01: Name
Enter your full professional name.	Please write your answer here:
A02: Practice Name (if applicable)
Enter the full name of your practice or organization you work for (if applicable)	Please write your answer here:
* A03: Primary Office Address
Enter the STREET address where your primary business is located	Please write your answer here:
* A04: Practice City
Enter the CITY where your primary business is located	Please write your answer here:
* A05: State
Enter the STATE where your primary business is located	Please choose *only one* of the following: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* A06: Zip
Enter the ZIP CODE where your primary business is located	Please write your answer here:
* A07: Business Phone
Enter the TELEPHONE NUMBER of your primary business	Please write your answer here:
A08: Business Fax
Enter the FAX NUMBER of your primary business	Please write your answer here:
A09: Business E-Mail
Enter the E-MAIL ADDRESS of your primary business	Please write your answer here:
Professional Associates Enter the full professional name of any associates with whom you work
B1: Associates
Enter the full professional names of your associates (One per line)	Please write your answer here:
Additional Office Locations If your practice extends to more than one location, please enter the location information for that practice here
C1: Additional Practice Name
Enter the FULL NAME of a second practice if applicable	Please write your answer here:
C2: Office Address
Enter complete ADDRESS including city, state and zip of additional practice	Please write your answer here:
C3: City
Enter the CITY where the additional practice is located	Please write your answer here:
C4: State
Enter the STATE where your primary business is located	Please choose *only one* of the following: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
C5: Zip
Enter the ZIP CODE of the additional practice	Please write your answer here:
C6: Business Phone
Enter TELEPHONE NUMBER including area code of the additional practice	Please write your answer here:
C7: Business Fax
Enter the FAX NUMBER of the additional practice	Please write your answer here:
ART Program Affiliation If you are affiliated with an ART program, enter the information about the program here
D1: ART Program Affiliation
Enter the FULL NAME of the ART program with which you are affiliated	Please write your answer here:
D2: Street
Enter the STREET ADDRESS of the ART program with which you are affiliated	Please write your answer here:
D3: City
Enter the ZIP CODE of the ART program you are affiliated with	Please write your answer here:
D4: State
Enter the STATE where the ART program you are affiliated wiith is located	Please choose *only one* of the following: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
D5: Zip
Enter the ZIP CODE of the ART program you are affiliated with	Please write your answer here:
Specialty Area Classifications Check each specialty are for listing in the resource directory
* E1: Specialty Areas
	Please choose *all* that apply: Adoption agency Attorney Mental Health Professional Surrogacy Agency Reproductive Endocrinologist Egg Donation Agency Urologist Sperm Donation Agency OB/GYN Acupuncturist Chiropractor Massage Therapist Naturopath Other:
E2: Please describe the services that you provide, especially those relevant to the LGBT community, e.g. willing to work with single intended parents, etc...
	Please write your answer here:
E3: Please list all services that you or your agency offer:
	Please write your answer here:
Fees for services
* F1: Are you a participant in any managed care plans?
	Please choose *only one* of the following: Yes No
Education and Experience
G1A: Enter details of degree obtained
	Please write your answer(s) here: School: Degree: Year:
G1B: Enter details of degree obtained
	Please write your answer(s) here: School: Degree: Year:
G2A: License or Certificate
	Please write your answer(s) here: License/Certificate: State: License/Certificate #:
G2B: License or Certificate
	Please write your answer(s) here: License/Certificate: State: License/Certificate #:
G2C: License or Certificate
	Please write your answer(s) here: License/Certificate: State: License/Certificate #:
G3: Rsidency
	Please write your answer(s) here: Location: Year:
G4A: Other Training
	Please write your answer(s) here: Organization: Year:
G4B: Other Training
	Please write your answer(s) here: Organization: Year:
G5: Are you a member in good standing with your State Board in your field? If no, please explain on a separate piece of paper.
	Please choose *only one* of the following: Yes No
G6: Enter State Boards
	Please write your answer(s) here: Board: State: Board: State:
Professional Organizations
H1: Please indicate any professional organizations to which you belong:
	Please choose *all* that apply: Professional Member of The American Fertility Association American Society for Reproductive Medicine National Certification Board for Therapeutic Massage and Bodywork National Certification Commission for Acupuncture and Oriental Medicine
H2: Other professional organizations
	Please write your answer(s) here: Organization: Organization: Organization: Organization:
Submit Your Survey. Thank you for completing this survey. Please fax your completed survey to: .