Member Application

Please complete the required information requested here. Required information have the * next to them.

Organization Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Primary Email *

Organization Website/URL *

Organization Head *

First

Last

Job Title *

Contact Person *

First

Last

Job Title *

Is your organization a CMHC? *

Services Provided *

Mission Statement *

Primary Service Area *

Population Served *

Is the organization incorporated as an Indiana non-profit? *

Is the organization tax exempt as a 501(c)(3)? *

Operating budget for most recent fiscal year $ *

# of Full-Time Employees *

# of Part-Time Employees *

# of Board Members *

# of Volunteers *

Organization Logo

Click or drag a file to this area to upload.

Please upload your organization logo here. Format: .jpg, .png, .gif Minimum width: 500 pixels Minimum height: 260 pixels Maximum file size: 5 MB

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