Alliance Membership Application

Name of Person Completing Application(Required)

First Last

Title(Required)

Email(Required)

Organization Name(Required)

Phone(Required)

Organization Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Website(Required)

Social Media Handles

Name of Board President/Chairperson(Required)

First Last Email

Name of Executive Director(Required)

First Last Email

Please provide the years below using the YYYY format (i.e. 1999 or 2008). If any do not apply please leave blank.

Year of Establishment

Year of Incorporation

Year of Non-Profit Status

EIN Number

Annual Dues Level(Required)

$250 per year - Less than $50,000 annual budget

$550 per year - $50,000 to $149,999 annual budget

$850 per year - $150,000 to $499,999 annual budget

$1,400 per year - $500,000 and above annual budget