Corporate Membership Application

Please complete the new member application below and select a payment method. If you have any questions please contact NIA and a staff person will be happy to assist you.

PLEASE COMPLETE ALL FIELDS

All fields marked with * are required.

Desired Username *

A username is required.

Desired Password *

A password is required.

Repeat Password *

A repeat password is required.

Address 1 *

An address is required.

Address 2

City *

A city is required.

State/Province *

A state is required.

Zip *

A zip is required.

Country *

Company Name *

A company name is required.

Company Phone *

A company phone is required.

Company Fax *

A company fax is required.

Company Website *

A company website is required.

First name of applicant *

Applicant first name is required.

Last name of applicant *

Applicant last name is required.

Title *

Applicant title is required.

Phone *

Applicant phone is required.

Fax *

Applicant fax is required.

Email *

Applicant email is required.

Company Description *

A 50-word description of your company will appear in NIA's Member Directory and in the Meet Our Members section of the NIA website along with your company's basic contact information. This description offers your company the opportunity for current and new business contacts to learn more about your company's products and services. Please limit descriptions to 50 words or less. Descriptions exceeding 50 words may be subject to editing for the Directory.

Company description is required.

Designated (Key) Contact

Administrative/Office Personnel.

Designated (Key) Contact Name *

Contact name is required.

Designated (Key) Contact's Title *

Contact title is required.

Business Address *

Contact address is required.

Business Address 2

City *

Contact city is required.

State/Province *

Contact state is required.

Zip *

Contact zip is required.

Country *

Designated (Key) Contact's Phone Number *

Contact phone is required.

Designated (Key) Contact's Fax Number *

Contact fax is required.

Designated (Key) Contact's E-mail Address *

Contact email is required.