Please contact a CLM representative to ensure that you or your organization is eligible for a reciprocal membership. FY20 Reciprocal Membership Form Organization InformationOrganization Name:*Organization Doing Business As:Please fill out if you'd like to be listed under your DBA credentialsAddress* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Phone:*Website:* Are you a current member of any of the following membership organizations?Check all that apply ABH ADDP maaps MNN The Provider's Council Other None Approximately how many MA children, youth, and families does your organiz-ation serve on an annual basis?Contact InformationPresident/CEO:*The President/CEO staff member is approved representative of the organization. This person can attend and vote at CLM member meetings, as outlined in CLM's bylaws. If you would prefer another senior level staff member to be attend and vote at CLM member meetings, please fill out the representative information below. First Last Title Email Alternative Representative:Please fill out the name and title of the senior level staff person who your organization is authorizing to be a designated CLM representative- who can attend and vote at Member Meetings in lieu of the President/CEO. First Last Title Email Executive Assistant*To the President/CEO (or alternative representative as appropriate) First Last Email CFO/Billing Contact* First Last Title Email HR or Operations Director First Last Title Email Membership Renewal Point of Contact* First Last Title Email CLM BenefitsIf you would like an overview of CLM's membership benefits before completing this renewal form, please visit our website. Otherwise a copy of the membership benefits will be sent to member's President/CEO (or designated representative) upon completion of this form.Membership DuesReciprocal members are non-dues paying members that are designated as such by CLM's board of directors. Such persons or organizations serve in an honorary capacity and have no rights and responsibilities as a full member per CLM's bylaws. The questions below are still necessary towards completing your membership renewal.Total Organizational Budget*Total Budget for Children and Family Services:*Application SubmissionName of Person Filling out this Form* First Last Title Email To complete this application, please acknowledge the following statements:* I am authorized to submit this application on behalf of my organization
