Organization Membership Application
Please fill out the following information to apply for membership.
Membership Type:
*
Organization Agency
Professional Individual i.e. LPCs, LMFTs, MSWs, etc.
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
Please provide a short description of what you do:
*
Current Operating Budget:
*
Less than $100,000
Between $100,000 and $500,000
Between $500,000 and $1M
Between $1M and $3M
Between $3M and $5M
Between $5M and $7M
Between $7M and $10M
Between $10M and $20M
Greater than $20M
I understand that my agency's annual dues will be $300 as our operating budget is less than $100,000
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $600 as our operating budget is greater than $100,000 but less than $500,000
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $1,000 as our operating budget is greater than $500,000 but less than $1 Million
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $2,000 as our operating budget is greater than $1 Million but less than $3 Million
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $3,000 as our operating budget is greater than $3 Million but less than $5 Million
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $4,000 as our operating budget is greater than $5 Million but less than $7 Million
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $5,000 as our operating budget is greater than $7 Million but less than $10 Million
*
Please Select
Yes
I do NOT understand
I understand that my agency's annual dues will be $10,000 as our operating budget is greater than $10 Million but less than $20 Million
*
Please Select
Yes
I do NOT understand
My agency is interested in the $25,000 annual Sponsor Membership
*
Please Select
Yes
No
Exact Operating Budget:
*
Please do not use $ or decimals
What benefits are you seeking?
*
Discounts on Events/Training
Partnership with Other Agencies
Networking Opportunities
Volunteer Opportunities
Other
Upload your approved agency logo:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: