Company or Organization* (Provide your company or organization name as you would like it to appear on your WPFL certificate and on the membership roster of the Workplace Partnership for Life (e.g., General Motors, United Autoworkers). Contact Information Name* City* Zip* Fax Web Site Street Address* State/Province* --United States--AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming--Canada--AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorth West TerritoryNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon TerritoryNot Applicable Phone* E-mail* If you're human leave this blank:
