Membership Application
Name
*
First Name
Last Name
Title
*
Email
*
example@example.com
Would you like to add an alternate contact?
Yes
No
Alternate Contact
First Name
Last Name
Title
Email
example@example.com
Organization Information
Organization Name
*
Organization Type
*
Please Select
Government
Nonprofit
For Profit
Individual
Website URL
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email
*
example@example.com
Year Founded
*
Organization description and mission statement
*
Membership Information
Membership Levels
Voting ($500)
Member organizations shall be represented by chief administrators with decision-making authority on behalf of their organization.
Members may appoint an alternate to represent them and their organizations by notifying the BCCN membership coordinator.
The appointed alternate may vote in the absence of the chief administrator.
Up to five additional staff members of the organization can attend meetings as non-voting members.
Alternate ($200)
Non-governmental organization members may appoint one alternate who represents the organization and can vote in the absence of the chief administrator.
Up to two organizational representatives may attend BCCN meetings each month.
Non-Voting ($50)
Individual or one organization representative attending monthly Networking meetings and Collaborative/CoC meetings.
Networking members have no voting privileges.
Please choose your membership level:
*
Voting ($500)
Alternate ($200)
Non-Voting ($50)
Sign and Submit Application
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: