Regional Hub application

Organization Name*

Address of organization*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

Name of authorized representative*

First Last

Title of representative*

Representative email (if different from organization e-mail)

Representative phone (if different from organization phone)

Select the region you want to represent*

Choose one of the regions below. For regions not corresponding to a PINA-designated region, choose "Other" and enter description of region you wish to represent.

Total number of members on management team*

Enter as a number, not a word.
"Management team" means your board, executive committee, or other equivalent leadership group for your organization.

Names of PINA members on management team*

Please enter one name per line.
"Management team" means your board, executive committee, or other equivalent leadership group for your organization.
NOTE that PINA members must constitute a majority of the management team for a Regional Hub.

Brief CVs/resumes for management team*

Please provide brief CVs or resumes for members of the management team, in PDF format only. You can select multiple files to submit.

Drop files here or

Tell us why you should represent PINA in your region*

After reviewing our Regional Hub policy and criteria, please tell us why you believe your group would be the best PINA representative in your hub region. Include affirmation of meeting the PINA criteria for a regional hub. If PINA has already designated a hub for the region you select, we will direct you to affiliate with that hub, integrate your efforts with theirs, or otherwise cooperate with them. If, following consultation with the existing hub, it becomes apparent to all parties that a subdivision of the region is appropriate, PINA will take a role in facilitating negotiations.

Potential field advisors

Please enter names (one per line) of PINA diplomates in your region who might be willing to serve as a Field Advisor in the diploma program (this is paid work).

Estimated date of board member nomination*

When (month & year) would you be prepared to nominate a director to the PINA board?
(nominations are subject to PINA board approval)

PDC Date*

PDC Location*

PDC Instructor(s)*

Organization's legal structure*

For example 501(c)3, Mutual Benefit Corp, 501(c)6, Cooperative, Nonprofit not recognized by IRS, other (explain).

Jurisdiction in which the legal entity is chartered*

Organization's chartered purpose*

Organization's current primary activities*

Tell us who you are*

Please provide a succinct statement of who you are, as an organization. Include a short statement of mission and history.

User Name*

Choose a user name for your organization's PINA web site login.

Regional Hub membership*

Price: $120.00

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.

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