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<h2>Join the U.S. Positive Women's Network Today!</h2>

<p style="text-align: center;"><img width="300" height="99" src="http://salsa.democracyinaction.org/o/2500/images/PWNheader.tiff" alt="" /></p>
<p style="text-align: center;">Strengthening the Collective Power of Women with HIV</p>
<p style="text-align: center;">All information is confidential. &#160;If you have questions, please send an email to: pwn(at)womenhiv.org or call: 510-986-0340 ext 316.</p>
<p></p>




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<label for="f6">Street 2</label>
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<label for="f7">City<span class='required'>*</span></label>
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<label for="f8">State/Province<span class='required'>*</span></label>
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  <option value="">Select a state</option>
  <option value="AL" >Alabama</option>
  <option value="AK" >Alaska</option>
	<option value="AS" >American Samoa</option>
	<option value="AZ" >Arizona</option>
	<option value="AR" >Arkansas</option>
	<option value="CA" >California</option>
	<option value="CO" >Colorado</option>
	<option value="CT" >Connecticut</option>
	<option value="DE" >Delaware</option>
	<option value="DC" >D.C.</option>
	<option value="FL" >Florida</option>
	<option value="GA" >Georgia</option>
	<option value="GU" >Guam</option>
	<option value="HI" >Hawaii</option>
	<option value="ID" >Idaho</option>
	<option value="IL" >Illinois</option>
	<option value="IN" >Indiana</option>
	<option value="IA" >Iowa</option>
	<option value="KS" >Kansas</option>
	<option value="KY" >Kentucky</option>
	<option value="LA" >Louisiana</option>
	<option value="ME" >Maine</option>
	<option value="MD" >Maryland</option>
	<option value="MA" >Massachusetts</option>
	<option value="MI" >Michigan</option>
	<option value="MN" >Minnesota</option>
	<option value="MS" >Mississippi</option>
	<option value="MO" >Missouri</option>
	<option value="MT" >Montana</option>
	<option value="NE" >Nebraska</option>
	<option value="NV" >Nevada</option>
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	<option value="NJ" >New Jersey</option>
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	<option value="NC" >North Carolina</option>
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	<option value="MP" >Northern Mariana Islands</option>
	<option value="OH" >Ohio</option>
	<option value="OK" >Oklahoma</option>
	<option value="OR" >Oregon</option>
	<option value="PA" >Pennsylvania</option>
	<option value="PR" >Puerto Rico</option>
	<option value="RI" >Rhode Island</option>
	<option value="SC" >South Carolina</option>
	<option value="SD" >South Dakota</option>
	<option value="TN" >Tennessee</option>
	<option value="TX" >Texas</option>
	<option value="UT" >Utah</option>
	<option value="VT" >Vermont</option>
	<option value="VI" >Virgin Islands</option>
	<option value="VA" >Virginia</option>
	<option value="WA" >Washington</option>
	<option value="WV" >West Virginia</option>
	<option value="WI" >Wisconsin</option>
	<option value="WY" >Wyoming</option>
        <option value="AA" >Armed Forces (the) Americas</option>
        <option value="AE" >Armed Forces Europe</option>
        <option value="AP" >Armed Forces Pacific</option>
	<option value="AB" >Alberta</option>
	<option value="BC" >British Columbia</option>
	<option value="MB" >Manitoba</option>
	<option value="NF" >Newfoundland</option>
	<option value="NB" >New Brunswick</option>
	<option value="NS" >Nova Scotia</option>
	<option value="NT" >Northwest Territories</option>
	<option value="NU" >Nunavut</option>
	<option value="ON" >Ontario</option>
	<option value="PE" >Prince Edward Island</option>
	<option value="QC" >Quebec</option>
	<option value="SK" >Saskatchewan</option>
	<option value="YT" >Yukon Territory</option>
	<option value="ot" >Other</option>
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<label for="f10">Organization</label>

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					<label for="f11" >Occupation</label>
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					<label for="f1" >Interested in joining PWN's policy workgroup (HIV+ women only)</label>
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<option value="0" >Female</option>
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					<label for="f4" >Please let us know how you want to be involved with the PWN!<span class='required'>*</span></label>
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