IDSA State and Regional Affiliate Assessment & Questionnaire

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Please provide the contact information for your State & Regional Society organization.

Contact Name:

Contact Title:

Contact Email:

Contact Phone:

Organization Mailing Address

Organization:

Street Address:

City:

State:

Zip Code:

State or Region Covered by your organization?

Name of your State & Regional Society:

Website Address (if applicable):

Is the organization a registered (501 c3, c6, etc.) non-profit organization?

YesNo

Does the organization have written bylaws?

YesNo