NARPM Atlanta Affiliate Membership Application

NARPM Atlanta Affiliate Membership Application
What type of registration is this?*

New MembershipUpdate Existing Membership
Contact Information
Company Name*
Primary Contact's Name*

First NameLast Name
Primary Contact's Title*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Website Address*
Billing Contact Name*

First NameLast Name
Billing Contact Email Address*
example@example.com
Product/Service Info
Describe your product/service as you want it to appear on the NARPM website:*

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Please select the primary category of product/service you offer:*
This is the category you will be placed under on the NARPM website
Describe Other:*
Upload your company logo to be used on the NARPM Atlanta website. (.jpg, .jpeg, .png)*

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Please read the NARPM Affiliate Code of Conduct here.
I agree to comply with the NARPM Affiliate Code of Conduct (linked above), and I agree that my membership may be cancelled without refund if I am found by the Atlanta Chapter Board of Directors to have violated the Code:*

I Agree
Membership Info
How did you hear about the NARPM Atlanta Chapter?*
Who referred you?*
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My Products*

NARPM Affiliate Membership

$500.00

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Total

$0.00

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First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Contact Information