Southern Region MSDC
Corporate Membership Application
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
Key Corporate Supplier Diversity Advocate or Influencer
Please list first and last name
Key Corporate Supplier Diversity Title
Key Corporate Supplier Diversity Email
Key Corporate Supplier Diversity Phone Number
What Type of Membership Describes You?
National/International
Local/Regional
Is Your Organization a National Member of the NMSDC?
YES
NO
Does Your Organization Have An Established Supplier Diversity Programs?
YES
NO
Does Your Organization require MBES To Be Certified?
YES
NO
If "YES," What Type of Certifications Do You Accept?
SBA
NMSDC Regional Affliliates
8(a)
WBENC
State or Local
Self-Certified
Other
Are You a Federal Contractor?
YES
NO
Is Your Organization Interested in Learning More About How You Can Support the SRMSDSC and Its Regional Suppliers?
YES
NO
Select Corporate Membership Level
prev
next
( X )
Corporate Membership Level 1
For Corporate members with less than $1 billion in annual revenue.
$
4,500.00
Corporate Membership Level 2
For Corporate members with $1 to $5 billion in annual revenue.
$
6,500.00
Corporate Membership Level 3
For Corporate members with $5 to $10 billion in annual revenue.
$
8,500.00
Corporate Membership Level 4
For Corporate members with over $10 billion in annual revenue.
$
10,000.00
Direct Invoice
Please select this option if you prefer to be invoiced. Please don't forget to select the Corporate Membership Level in the notes section.
$
Free
Corporate Membership Level
Level 1
Level 2
Level 3
Level 4
Signature
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: