AFFILIATE MEMBERSHIP APPLICATION

Legal Entity Name:
DBA Name:
Federal Employer Identification Number (EIN):
Website:
Main Company Email:
Main Company Phone Number:
Social Media Links:
facebook.com/
x.com/
instagram.com/
linkedin.com/
Applicant Details
Name:
Email:
Phone:
Position:
Headquarters Address:
Street Address:
City:
State:
Zip Code:
Mailing Address:	(if different from headquarters address)
Street Address:
City:
State:
Zip Code:
Annual Revenues:
	Under $1 Million
	Between $1 Million and $5 Million
	Between $5 Million and $10 Million
	Over $10 Million
Do you have more than 1000 members?	Yes No
If so, how many members do you have?

I state that the information I have provided is true and accurate and that I agree to allow the AGSC™ to contact me in the future.

I am not a robot: 0 + 1 =

Applicant Details