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. Organization's Website:

* 5. Primary Contact's Name:

* 6. Primary Contact's Email Address:

* 7. Primary Contact's Phone Number:

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

* 9. Organization's Federal Tax ID:

* 10. Organization's Year of Formation:

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