NIMA Membership Application

MEMBERSHIP APPLICATION

To apply for membership, please complete all questions.
Organization Name
As you would like it to appear on membership roster.
Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Website
Years in Business
Number of Employees
Industries Served (Check all that Apply)
Brief Description of your Organization's Products and/or Services
This will be used in your membership profile.
Organization Logo

This will be used in your membership profile.
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Primary Contact Name

First NameLast Name
Primary Contact Email
example@example.com
Primary Contact Work
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Cell
Please enter a valid phone number.Format: (000) 000-0000.
HR Contact Name (if different than above)

First NameLast Name
HR Contact Email
example@example.com
HR Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Address
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Membership Type (Annual Dues)
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Enterprise
>200 Employees

$2,500



Large
101-200 Employees

$1,500



Medium
51-100 Employees

$1,000



Small
21-50 Employees

$750



Micro
1-20 Employees

$500



Affiliate
Education, EDC, Government, Peer Association Organizations

$250
Date of Application

MonthDayYear
Date
Should be Empty:

MEMBERSHIP APPLICATION