Online Membership Application Form

Organization Name*:

Website:

Billing Street*:

Billing City*:

Billing State/Province*:

Billing Zip/Postal Code*:

Billing Country*:

Annual Budget/Revenue*:

Sector*:

Industry*:

Minority-Owned Business? YesNo

Woman-Owned Business? YesNo

STEP 2
Contact information

Primary Representative

First Name*:

Last Name*:

Title*:

Email Address*:

Department*:

Phone*:

Secondary Representative

First Name*:

Last Name*:

Title*:

Email Address*:

Department*:

Phone*:

Who should be named on your membership dues invoice?
Primary RepresentativeSecondary RepresentativeOther:

STEP 3
Select membership role(s)

Please select at least one role in which your organization will participate in the Council. Please refer to the roles webpage and the dues associated with each based on annual budget/revenue. Please note that selecting multiple roles means you’ll pay dues for both roles, with a 40% multi-role discount on the more expensive due.

Please select your role(s):
PurchaserSupplierPublic Interest Advocate

STEP 1
Organizational Information

STEP 2
Contact information

STEP 3
Select membership role(s)

STEP 4
SPLC Summit