In addition to completing this application, please remember to also submit your Member Group fee.

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* 1. Name of Organization:

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* 2. Organization's Mailing Address:

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* 3. Organization's Physical Address:

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* 4. City:

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* 5. State:

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* 6. Zip Code:

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* 7. County:

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* 8. Organization's Website:

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* 9. Primary Contact's Name:

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* 10. Contact's Email Address:

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* 11. Contact's Phone Number:

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* 12. Additional Contacts: (optional)

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* 13. Is your organization a 501(c)(3)?

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* 14. What is your organization's federal tax ID?

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* 15. What is your organization's date of formation?

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