Membership Application Official Name of Organization*Name as you would like it to appear in WisPQC materials. Website Upload Organization Logo Drop files here or Accepted file types: jpg, gif, png. *Please Note: Membership will not be confirmed without the ability of the WisPQC to use your organization's logo on WisPQC materials. Address* 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 Is your organization a hospital?*YesNoHas your facility completed the WAPC Levels of Care self-assessment surveys?YesNoFor more information on the WAPC Levels of Care initiative, go to the WAPC Web site, or call WAPC staff at 608-285-5858.What level obstetric services do you provide?Level ILevel IILevel IIILevel IVWe do not provide obstetric services.What level neonatal services do you provide?Level ILevel IILevel IIILevel IVWe do not provide neonatal services.Representative Contact InformationContact information for the designated representative who will be attending monthly meetings, via Webinar or face-to-face: Name*Email* Phone*Alternate Contact InformationContact information for possible alternate(s) who may be representing your organization instead of the designated representative. NameEmail PhoneDo you have another alternate name to add?*YesNoSecond Alternate NameEmail PhoneDo you have another alternate name to add?*YesNoThird Alternate NameEmail PhoneDo you have another alternate name to add?*YesNoFourth Alternate NameEmail PhoneUse the space below to share how you heard about WisPQC and who and/or what was most significant encouraging/supporting your involvement.*Electronic SignatureAccepted file types: jpg, gif, png.If available, the electronic signature of staff with authority to commit to membership of your organization. *Files must be no larger than 2MB.Typed Name of Signer*Date* Date Format: MM slash DD slash YYYY