FY20 Organization 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:* Accreditation Status* My organization is accredited by COA My organization is accredited by another accreditation provider My organization is not accredited 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 DuesCLM dues are based on the portion of an organization's budget that goes directly to providing services to children and families in Massachusetts. This includes ALL STATE CONTRACTS, GRANTS, THIRD-PARTY INCOME, OR OTHER REVENUE related to serving this population. Please provide your budget for the most current fiscal year. CLM will invoice the organization based upon your reported budget for CHILD AND FAMILY SERVICES only. Total Organizational Budget*Total Budget for Children and Family Services:*http://www.childrensleague.org/membership-dues/Dues Agreements* Select All I have reviewed the FY20 Dues document and understand that my organization will be invoiced at tier that correlates to my organization's total budget for children and family services I understand that my organization will be billed on or shortly after July 1st I understand that if I fail to pay by September 30th, I will no longer be considered a CLM member and removed from CLM's rosters and benefits 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
