Membership Application & Dues

Applications and Dues must be submitted by July 1st, 2020

Membership for Member / Affiliate Orgs.

Please fill out the following form and upload the required documentation.

Organization Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

Organization Website / URL

Membership Type (please select):

Member Organization
Affiliate Organization
Allied Medical Professional & Healthcare Provider
Allied Corporate Benefactor

Chief Executive Name:

Title:

Contact info if different from above:

Important

The CSD representative you list on this application will be responsible for all official communication and voting with the CSD. Although other names may be added to the listserv, those names will not be included on the official listing with auxiliary organizations. Official information and/or invitations will only be sent to the CSD rep designated on this form.

Designated Coalition Representative

(official rep to the CSD)

Designated CSD representative Name and Title

Email Address:

Mailing address if different from above:

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Optional*: Names and email addresses of individuals other than designated representative, who shall be added to the CSD listserv (up to 2 or attach additional page). This does not change the line of communication. The designated rep listed will receive invitations and notices from outside organizations when they are not posted on the listserv. It will be up to the CSD designated rep to forward such correspondence to the appropriate parties.

Please include the following for NEW APPLICANTS:

ENTIRE most recent 990
Clinical Photo of Disease
Updated organization logo

Please include the following for RENEWAL:

Updated organization logo
INDUSTRY: Primary Contact Name, Cell phone, Email, and Corporate mailing address

For security purposes, please answer the following problem in order to submit this form: *

Comment

Dues

Please click the following button to pay any dues owed.

If this number is less than $250, please pay the minimum of $250.
If this number is more than $1,500, please pay the maximum of $1,500.