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

* 1. Name of Organization:

* 2. Organization's Mailing Address:

* 3. Organization's Physical Address:

* 4. City:

* 5. State:

* 6. Zip Code:

* 7. County:

* 8. Organization's Website:

* 9. Primary Contact's Name:

* 10. Contact's Email Address:

* 11. Contact's Phone Number:

* 12. Additional Contacts: (optional)

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

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

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

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