Corporate Group Membership - Interest Form
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Employer or Practice
*
Location of Employer or Practice (City, State, Zip Code)
*
Which Best Describes Your Interest:
I am a midwife and an employee. I am interested in setting up group memberships for me and my colleagues. Someone else at my organization will be the contact with ACNM for payment information and membership details.
I am a practice director or business owner. I am interested in group memberships for my employees. I will be the point of contact with ACNM for payment information and membership details.
I work in Administration, HR or Finance for my company and am interested in setting up corporate group memberships for our employees. I will be the point of contact with ACNM for payment information and membership details
Employer Contact
*
First Name
Last Name
Employer Contact Email
*
example@example.com
Employer Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Policy on Paid Memberships
*
Our organization has an existing policy or benefit for employees to pay for membership in professional associations
Our organization has not previously offered paid memberships in professional associations as an employee benefit
Contact Information for New Members
*
We have finalized our list of employees / midwives who will be joining through this corporate group membership, and will send that list to ACNM
We have not yet finalized the list of employees / midwives who will be joining through this corporate group membership
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