Membership Application

Also in PDF format.

Agency Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Website:
Agency Exec. Director/President:
Agency Contact:
Contact Email Address:

Agency Mission:

Please list the specific services your agency provides.

Please list your agency site locations.

Counties Served:
Number of Full-Time Staff:
Part-Time Staff:
Number of Active Volunteers:
Size of Board:
Number of Board Meetings Per Year:
Annual Budget:

What do you hope to gain by being a member of NYSAFSA?
(Please select all that apply)

Professional (CEO) development	Peer guidance & support
Board development	Legislation & advocacy info
Fundraising skills	Info about funding sources
HR management	Info about program delivery

Statewide networking
Other:

Enter your email here if you would
like to recieve a copy of this form:

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