INABC Membership ApplicationApplication Instructions Please fully complete the application form below. Upon completion, you will be redirected to a new page where you will complete payment via PayPal.Membership Type2024 Membership *New Member ApplicationRenewal ApplicationChoose One *Professional ($100 annually)Agency 6-15 ($600 annually)Agency 16-25 ($1100 annually)Agency 26+ ($1600 annually)Retiree ($250 lifetime)Student ($50 annually)Contact InformationName *Agency Name (for Agency Members) Mailing Address (Street, City, State, ZIP Code) *** please note that your contact address will be listed within the INABC.org directory unless specifically requested otherwise **Email *Telephone *Website URL Your Current ServicesCounties Served Please check all areas / counties that you, or your agency, serve, or are willing to serve. If you serve the entire state, simply check "State-Wide Services". If you are not currently providing service, simply note "No Counties Served".No Counties ServedState-Wide ServicesArea 1 – Lake, Porter, Jasper, Newton, Pulaski, StarkeArea 2 – Elkhart, LaPorte, Kosciosko, Marshall, St. JosephArea 3 – Adams, Allen, DeKalb, Huntington, LaGrangeArea 4 – Benton, Carroll, Clinton, Fountain, Tippecanoe, Montgomery, Warren, WhiteArea 5 – Fulton, Cass, Miami, Wabash, Howard, TiptonArea 6 – Blackford, Delaware, Grant, Henry, Jay, Madison, RandolphArea 7 – Clay, Parke, Putnam, Sullivan, Vermillion, VigoArea 8 – Marion, Boone, Hamilton, Hancock, Shelby, Johnson, Morgan, HendricksArea 9 – Fayette, Rush, Franklin, Union, WayneArea 10 - Monroe, OwenArea 11 - Bartholomew, Brown, Decatur, Jackson, JenningsArea 12 - Dearborn, Jefferson, Ohio, Ripley, SwitzerlandArea 13 - Davies, Dubois, Knox, Greene, Martin, PikeArea 14 - Clark, Floyd, Harrison, ScottArea 15 - Crawford, Lawrence, Orange, WashingtonArea 16 - Gibson, Perry, Posey, Spender. Vanderbaugh, WarrickNumber of Consumers Served via Medicaid Waiver Funding *Number of Consumers Served via State Line Funding *Number of Consumers Served via all Other Funding Sources *Additional Information for Agency MembersChief Executive Officer CEO Email Primary Agency Contact Person Primary Contact Email All Consultant Names and Email Addresses *A list of all affiliated consultants, along with their email address, is necessary for the purposes of CEU session attendance verification PRIOR to issuance of CEU certificates. Please add all information in the following format: John Smith - jsmith@email.comWho should be copied on all INABC related emails ? Please check all boxes that apply.CEOPrimary Agency ContactAll ConsultantsIs your agency a subsidiary organization ? YesNoParent Organization Complete and Confirm Your ApplicationI have read and agree to uphold the INABC Code of Ethics *Yes, I have read the Code of Ethics and will abide.No, I have not yet reviewed the Code of Ethics.Electronic Signature *Please confirm with your name that all the above information is correct.Today's Date of Application * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: