AMSA Partnership Payment Form
Full Name of Partner Contact
*
Prefix
First Name
Middle Name
Last Name
Suffix
Name of Organization joining AMSA
Contact Email
*
example@example.com
Contact Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Let us know the names and email addresses of those from your organization who should receive the AMSA Weekly Newsletter and other AMSA benefits
REGISTRATION OPTIONS
*
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Nonprofit (under $1,000,000 annual income)
$
250.00
Partnership includes all identified organization employees. A full receipt listing all partnership benefits and conditions will be emailed shortly after purchase.
Nonprofits (over $1,000,000 annual income)
$
500.00
Partnership includes all identified organization employees. A full receipt listing all partnership benefits and conditions will be emailed shortly after purchase.
Colleges, universities, research institutes
$
1,000.00
Partnership includes all identified institution employees. A full receipt listing all partnership benefits and conditions will be emailed shortly after purchase.
Cities under 50,000 population
$
500.00
Partnership includes all identified city employees. A full receipt listing all partnership benefits and conditions will be emailed shortly after purchase.
Cities over 50,000 population
$
1,500.00
Partnership is inclusive of the city department which registers. A full receipt listing all benefits and conditions will be emailed shortly after purchase.
Counties
$
1,500.00
Partnership is inclusive of the county department which registers. A full receipt listing all benefits and conditions will be emailed shortly after purchase.
States
$
3,000.00
Partnership is inclusive of the state department which registers. A full receipt listing all benefits and conditions will be emailed shortly after purchase.
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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