Indiana Council Partner Program - Indiana Council of Community Mental Health Centers (Indiana Council)

Thank you for your interest in Indiana Council’s partner program. Your partnership is effective for one year beginning the date your application is processed. Please, complete the membership application below. (Updated Nov 2022)

Company Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Website / URL

Phone

Organization Email

Primary Organization Description

Please list a description of your organization’s services or products. (limited to 200 words)

Membership Classification

Choose your organization’s membership type

Partner Level: $3,000
Associate Level: $4,000
Executive Level: $6,000

WBE/MBE

Please provide your WBE/MBE certification number or your 501 c 4 tax identification code

REPRESENTATIVES

Each organization may have two representatives on ICCMHC’s communication list.

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Please upload a copy of your logo here

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