MHC Membership Application
Please fill out the following information to apply for membership.
Organization/Agency Name:
*
Membership Contact Full Name
*
First Name
Last Name
Membership Email Address
*
example@example.com
Membership Phone Number
*
Please enter a valid phone number.
CEO Full Name
*
First Name
Last Name
CEO Email Address
*
example@example.com
CEO Phone Number
*
Please enter a valid phone number.
Address - If you have different mailing, billing, and physical please provide them all:
*
Agency Type - Choose all relevant options
*
Academic
Counseling/Social Work
Non-Profit
Food Pantry
For-Profit
Housing
Domestic Violence
Hospital/Treatment Center
Law Enforcement
City/County
Other
Description of your agency:
*
Current Operating Budget:
*
$00.00
What benefits are you seeking?
*
Discounts on Events/Training
Partnership with Other Agencies
Networking Opportunities
Volunteer Opportunities (Committee Involvement)
Other
Upload your approved agency logo:
*
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