Membership Application (non-APG)

Main Motivation

Membership Level

Organizational ($250/yr)

Individual ($150/yr)

Who is paying the AAPG membership fee?

Organization

Individual

Personal Information

This section is about information pertaining to you.

Position/Title

First Name

Last Name

Primary Phone

Primary Email (Please double check the spelling!!)

Secondary Email

Personal Information (cont.)

This section is a continuation of information pertaining to you.

Licenses/Certifications

Address

City

State

ZIP

Organizational Information

This section is about information pertaining to your organization.

Organization Name

Organization Phone

Organization Address

Address Line 1

Address Line 2

City

State

ZIP

Website

Year Organization Established

What is your organization's structure?

Nonprofit

For profit

Organizational Information (cont.)

This section is a continuation of information pertaining to your organization.

Director First Name

Director Last Name

Director's Licenses/Certifications

Director Phone

Director Email

Do you want your organization's director's contact information to be publicly posted in the AAPG Member Directory?

Yes

Organizational Information (cont.)

This section is a continuation of information pertaining to your organization.

About your organization

Can the above 'About' paragraph be displayed publicly on the AAPG's Member Directory webpage?

Yes

High Resolution Logo Upload (Vectorized Images Preferred)

Choose Image

Can the uploaded logo be displayed publicly on the AAPG's Member Directory webpage?

Yes

Additional Comments

Membership Payment

Please provide your payment details.

Name on Card

Membership Type

Organiational

$250 for each year

Individual

$150 for each year

Item	Price	Qty	Line Total
Membership Type - Organiational	$250	1	$250
Total			$250

Pay with Card (Stripe)