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 TypeChoose One *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 ServicesNumber 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 note if you prefer only the CEO and/or Primary Agency Contact to be included on the INABC mailing list - or - if you prefer ALL member consultants be included. Lastly add all contacts the following format: John Smith - jsmith@email.comIs 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>:
