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CoC Membership Renewal
for For-Profit Partners

Name of Business: *
Primary Member's Information

Name: *
Title
First Name
Last Name
Suffix
Job Title: *
Cell Phone Number: *
Email Address: *
Address: *  
Address Line 1
Address Line 2
City
State
Zip
Are you interested in joining Councils/Committees?  
Designee Information (if applicable)
Authorized to act on behalf of Primary Member

Designee's Name:  
Designee's Title:  
Designee's Cell Phone Number:  
Designee's Email Address:  
Organizational Updates

Website: *
Facebook Handle or Link:  
Twitter Handle or Link:  
Instagram Handle or Link:  
LinkedIn Handle or Link:  
YouTube Handle or Link:  
Please list any pertinent program changes here:  
CoC Conflict of Interest Policy

Do you agree to the Conflict of Interest Policy? *  
Voting Policy *
Disclosure *
Inquiry *
Conflict of Interest, Additional Information:  
Other

Please enter the number 1 here: *  

Membership dues for For-Profit Partner Members are $500.00 annually.