Institution Primary Contact Name Email Address Phone Number Mailing Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Please provide names and email addresses for listserv participants. There is no institutional limit to the number of listserv participants. Additional names and addresses can be added at any time by contacting Kim Browning. KYHEC Membership is $1,000 annually. Dues may be paid by check or by credit card (Visa or MasterCard only). Pay by Check Pay by Credit Card Please make your check payable to the University of Kentucky. Note on the check that it is for KYHEC membership. Mail checks to: Kim Browning UK Program for Bioethics Medical Sciences Building MS579 800 Rose St. Lexington KY 40536-0298 Please call Kim Browning at 859-323-8386 to provide your credit card information. If you have any questions or need assistance with this form, please contact Kim Browning at firstname.lastname@example.org or Becky Yarrison at email@example.com.