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

Name of Organization:

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* 1. Name of Organization:

Organization's Mailing Address:

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* 2. Organization's Mailing Address:

Organization's Physical Address:

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* 3. Organization's Physical Address:

Organization's Website:

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* 4. Organization's Website:

Primary Contact's Name:

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* 5. Primary Contact's Name:

Primary Contact's Email Address:

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* 6. Primary Contact's Email Address:

Primary Contact's Phone Number:

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* 7. Primary Contact's Phone Number:

Is your organization a 501(c)(3)?

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

Organization's Federal Tax ID:

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* 9. Organization's Federal Tax ID:

Organization's Year of Formation:

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* 10. Organization's Year of Formation:

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