daCi USA Organization/Institution Membership

Organization/Institution Name: * E-mail Address: * Contact Name: * Title/Occupation/Description: (15 words or less) for the Directory Organization/Institution membership includes membership privilages for up to 4 additional adult group members: Name: Email: Name: Email: Name: Email: Name: Email: Membership Type: * Organization/Institution - $100 Street Address: * City: * State: * --Select-- Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Washington, DC Wisconsin West Virginia Wyoming --Territories-- American Samoa Federated States of Micronesia Guam, DC Midway Islands Puerto Rico U.S. Virgin Islands Zip Code: * Phone Number: * Home Work Cell Phone Number (2) Home Work Cell Number of Children in your organization If you have a website, and would like the site listed on the LINKS page of the daCi USA website, please indicate your web address: Dues Acknowledgement: * Mailed Hard Copy Attachment to e-mail   Copy the text: * Not case-sensitive * Required ^