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* 1. Name of Organization:

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* 2. Is this organization non-profit or for-profit?

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* 3. What is your organization's interest in being a member of the Consortium? What would be helpful to your organization and staff?

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* 4. Organization is a (check all that apply):

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* 5. Which borough(s) / counties does your organization operate in? (check all that apply)

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* 6. What types of services does your organization provide? (check all that apply)

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* 7. Number of Staff:

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* 8. Annual Organizational Budget:

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* 9. Is your organization participating with a Performing Provider System for DSRIP, or related, project(s)? (e.g. Activities such as meetings, committees or contracts)

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* 10. Designated contact person for membership and billing related matters:

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* 11. Designated contact person for program related issues and registering staff for Consortium events and trainings:

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* 12. Any additional staff from your organization you would like to be added to our mailing list

You may also send a spreadsheet to info@bxconsortium.org with  names, job titles, and email addresses for all staff you would like added to our mailing list. There is no limit on the number of people you can add.

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