GMHA Membership Application Form

GMHA Membership Application Form
Company Name*
Membership Category*

Manufacturer $120/Floor, Due Monthly By the 15th of the Following MonthRetailer $250, $100 per Additional Location, $500 Cap, Billed AnnuallyCommunity $250, $100 per Additional Location, $500 Cap, Billed AnnuallySupplier $250, $100 per Additional Location, $500 Cap, Billed AnnuallyService Company $250, $100 per Additional Location, $500 Cap, Billed Annually
How many locations are you registering?*
Total Dues
Please provide a brief description of products.*
Please provide a brief description of services provided.*

Web Address (If Applicable)
Primary Office Phone*
Please enter a valid phone number.
Number of Physical Locations
Primary Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the mailing address the same as the primary physical address?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Physical Location 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Physical Location 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Location 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please contact Jimmy Cotty, GMHA Executive Director, at jimmy@gmha.com with additional physical locations beyond 4.

Primary Contact Name*

First NameLast Name
Title
Primary Contact Email*
example@example.com
Primary Contact Cell/Direct Number*
Please enter a valid phone number.
Will the Primary Contact also be the Primary Billing Contact?*

YesNo
Primary Billing Contact Name*

First NameLast Name
Primary Billing Contact Email*
example@example.com
Primary Billing Contact Cell/Direct Number*
Please enter a valid phone number.
You may add individuals to be included in GMHA communications. Please select how many individuals you would like to add, if any at all.*
Additional Contact 1*

First NameLast Name
Title
Email*
example@example.com
Cell/Direct Number
Please enter a valid phone number.
Additional Contact 2*

First NameLast Name
Title
Email*
example@example.com
Cell/Direct Number
Please enter a valid phone number.
Additional Contact 3*

First NameLast Name
Title
Email*
example@example.com
Cell/Direct Number
Please enter a valid phone number.
Additional Contact 4*

First NameLast Name
Title
Email*
example@example.com
Cell/Direct Number
Please enter a valid phone number.
To add more contacts, please contact Jimmy Cotty, GMHA Executive Director, at jimmy@gmha.com.

Payment Options*

CheckCredit Card
Total Amount Due
Please remit check in the total amount due above to:

Georgia Manufactured Housing Association, Inc.
PO Box 1538
Forsyth, Georgia 31029