MNA Membership Form

Primary Contact:

First Name(*)
Please enter your first name. Please do not use any special characters (except dash or apostrophe).

Last Name(*)
Please enter your last name, with no special characters.

Title(*)
Please enter your title.

Membership Type:(*)

Please select the membership type.

Organization(*)
Please enter your organization.

Department
Please enter XXX

Mailing Address 1(*)
Please enter your address.

Mailing Address 2
Please enter XXX

Mailing City(*)
Please enter your city.

Mailing State(*)
Please enter your state.

Mailing Zip(*)
Please enter a valid US zip code.

County(*)
County is required

Phone(*)
Enter your phone number (Eg. 5555555555)

(Eg. 5175553344)

Fax
Special characters not allowed. (Eg. 5555555555)

Email(*)
Email address is already assigned to a registered user or is invalid.

Website
Please enter your website URL (please include the http:// or https://)

Please include the http:// or https://

Tax Exempt 501(c)3
Please enter XXX

Tax Exempt 501(c)4
Please enter XXX

Tax ID
Please enter a valid tax ID (EIN).

How Did You Hear About MNA?
Please enter an alphanumeric value. Spaces ' ', periods '.', apostrophes ('), and hyphens '-' are also allowed.

Secondary Contact:

First Name
Please enter XXX

Last Name
Please enter XXX

Title
Please enter XXX

Email
Please enter an email address for the secondary contact. Please use an email address that is different from the primary contact. The email address cannot match an existing website user account.

Organization Information:

Full-time Employees
Please enter XXX

Part-time Employees
Please enter XXX

Only numeric value allowed

Volunteers (approximate)
Please enter XXX

Only numeric value allowed

Board Members
Please enter XXX

Only numeric value allowed

Payment:

For Nonprofit Organizations:
Annual Operating Budget   Annual Dues
    up to $100,000       $80
    $100,001-250,000       $160
    $250,001-500,000       $270
    $500,001-750,000       $370
    $750,001-1 million       $480
    $1 million-2 million       $580
    $2 million-4 million       $790
    $4 million +       $1,100

For Business Membership:
    Individual Consultant         $250      
    Consulting Firm/Partnerships       $500
    Corporations       $1,000

Nonprofit, please select your annual operating budget
Please select your annual operating budget

Businesses, please select category:
Please select a category

Annual Dues : $(*)
Invalid Input

Amount based on nonprofit budget or consultant/business category above

What is your Mission Statement
Please enter XXX

Select your organization type(s)
Please enter XXX

Hold control to select multiple items.

Select your business region(s)
Please enter XXX

Hold control to select multiple items

Select your business types
Please enter XXX

Hold control to select multiple items.

Would you like to enroll in Automatic Membership Renewal?
The automatic renewal option allows you to automatically extend your membership each year. Your credit card will be charged in the amount of your MNA membership dues on the renewal date. You may opt out at any time.

(*)
Invalid Input


Credit Card Number(*)
Please enter the card number

Expiration Month(*)
Please enter XXX

Expiration Year
Please enter XXX

CVV Security Code:(*)
CVV code is required.

Enter the 3 or 4 digit code on the back of your card.

Check this box if the billing address is the same as the mailing address
Invalid Input


First Name on Card(*)
Please enter your first name.
Last Name on Card(*)
Please enter your last name.
Company on Card
Please enter your organization.

(if applicable)

Billing Email(*)
Please enter the billing email

Billing Address 1(*)
Please enter your address.

Billing Address 2
Please enter XXX

Billing City(*)
Please enter your city.

Billing State(*)
Please enter your state.

Billing Zip(*)
Please enter a valid US zip code.

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