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Name of Applicant
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Proposed name of Association
*
Physical Address of Association
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City
and County*
State/Province
*
Postal Code
*
Mailing Address of Association
*
(if it's the same as above, write "same")
City and County
*
State
/Province*
Postal Code
*
Work Phone
Home Phone
Cell Phone
Email
*
Website
Purpose of Association
*
Proposed Membership Classifications
*
Founding Member
Charter Member
Senior Fellow
Fellow
Junior Fellow
Professional Member
Instructor Member
Facilitator Member
Associate Member
Provisional Member
Non-member Guest
Proposed members of the Board of Directors
*
Proposed President/Chairman/CEO
*
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