Become an Allied Organization

Allied organization membership form

Please fill out and submit the form below to become an Allied Organization member of PINA.
If you need more information about Allied Organization membership, see our Allied Organizations information page.

Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Organization website
User Name*
Choose a user name for your organization's PINA web site login.
Name of authorized representative*
First Last
Title of representative*
Representative email (if different from organization e-mail)
Representative phone (if different from organization phone)
Organization type*
- Non-profit
- For-profit
Organization's legal structure, if any (LLC, 501c3, Partnership, etc.)*
Name of a principal of the organization who has taken a PDC*
PDC Date*
PDC Location*
PDC Instructor(s)*
Organization's chartered purpose*
Organization's current primary activities*
Are there any specific ways in which your organization would like to partner with PINA?
Allied Organization membership*
Price:
PayPal account email*
Enter the email address that will be used to make the PayPal payment.
Total membership payment
$0.00
This is a subscription membership that will auto-renew yearly. You must have a PayPal account, or create one as you make this payment. If you cannot pay with a PayPal account, please contact us.
NOTE - after your payment is processed, a link to set your member login password will be e-mailed to your organization e-mail address!
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Email
This field is for validation purposes and should be left unchanged.

Become an Allied Organization

Allied organization membership form

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Send a Message about Transportation & Accommodations

Send a Message to Peter Bane, Executive Director

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