Membership Application

COSA MEMBERSHIP APPLICATION
If you are a new member, how did you find out about COSA?

N/A (existing or prior member)Search Engine (e.g., google, yahoo, etc.)Recommended by friend/colleagueSocial MediaEventOther
Other, please specify from above
Membership in COSA is open to any agency, firm, foundation, organization, or individual concerned with health and human services for residents in our area. A Corporate membership allows any staff or volunteer from your organization to participate in meetings, leadership positions, and the website listserve.
Membership Status
Type of Membership
Organization/Individual Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website
Contact for annual invoicing
Email
Listserve & Attendees
Please specify the contact information for individuals who will be regularly attending meetings and COSA events, or who you wish to be a part of our email distrbution list (ListServe) for members. A ListServe is a tool for communicating with a group of people via email (i.e. discussion group). One email message is sent to the "reflector" email address (listserve@cosaslc.org), and the software then sends the email to all of the group's members. More names can be added at a later date. Other representatives can attend at any time and/or be added by sending their contact information to info@cosaslc.org. Only one vote per member organization.
Primary Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Phone type

OfficeMobile
Email*
example@example.com
Name 2, if applicable.

First NameLast Name
Phone Number
Please enter a valid phone number.
Phone type

OfficeMobile
Email
example@example.com
Name 3, if applicable.

First NameLast Name
Phone Number
Please enter a valid phone number.
Phone Number Type

OfficeMobile
Email
example@example.com
Add other contacts for the listserve here, if needed.
Please indicate the sub-committee(s) upon which you or other representatives would like to serve, if any.

Community/Public RelationsEvent PlanningMembership
As a member, a URL link & short description of your organization's website is provided for viewers to obtain information about services & programs (2-3 sentences ONLYI!). Please do not cut and paste paragraphs of information. NOTE: Manager authorization is needed to approve the addition to the COSA website.
I will pay:

by check to COSA, PO Box 2356, Fort Pierce, FL 34954.by credit card at www.cosaslc.org using the form on the homepage
I have the authority to approve the addition of my organization's website URL to the COSA website and my signature signifies consent to do so.
Signature

Clear
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Please upload a high-quality version of your logo for the website link. You may also upload any informational flyers or brochures.

Cancelof
Should be Empty:

COSA MEMBERSHIP APPLICATION

Listserve & Attendees