Membership Application

Please fill in the form below, or alternatively, you can download it HERE.

Once you have completed the application CLICK HERE to pay online.

VisionServe Alliance Membership Application

Organization Name: (*)
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Organization Street Address(*)
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Organization City(*)
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Organization State(*)
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Organization Zip(*)
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Organization Phone Number(*)
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Organization Fax Number
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Organization Website(*)
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Organization Mission Statement
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CEO Name(*)
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CEO Email(*)
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CEO Direct Line or Extention Number
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CEO Cell Phone Number
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Population Served: Check all that apply(*)

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Services Provided: Check all that apply (*)

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Other:
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Membership Dues are based upon Annual Operating Expenses defined as: Gross expenses, less capital expenses, depreciation, and cost of raw materials, if member is a manufacturing facility. Please check the appropriate Annual Dues:

Organization’s Annual Operating Expenses & VisionServe Alliance Annual Dues(*)

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Notes:
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Questions?? Please contact Roxann Mayros This email address is being protected from spambots. You need JavaScript enabled to view it.