Organization Membership Application

Add Organization Basic Information
Add Organization Contact Information
Add Primary Contact
Add Alternate Contact
Membership & Add-ons
Review Totals

Organization Basic Information

Organization Name

Legal Name

Organization Type

Do you have a parent organization?

Parent Organization Name

Website

http://

Product/Service Description

NAICS Code

SIC Code

Number of Employees

Mississippi Congressional District

Mississippi Senate District

Please let us know some more about your organization

Maximum 1,000 characters.

Organization Contact Information

Address

Address Cont.

City

State

Zip Code

Country

Phone Number

Fax Number

Primary Contact

Add Yourself as Primary Contact

Email Address / Username

Password

Confirm Password

First Name

Last Name

Job Title

Copy primary contact address from your Organization Contact Information

Address Type

Mailing Address

Mailing Address Cont.

City

State/Province

Zip/Postal Code

Country

Work Phone

Work Extension

Fax

Cell Phone

Home Phone

Alternate Contact

Email Address / Username

Password

Confirm Password

First Name

Last Name

Job Title

Copy contact address from your Organization Contact Information

Address Type

Mailing Address

Mailing Address Cont.

City

State/Province

Zip/Postal Code

Country

Work Phone

Work Extension

Fax

Cell Phone

Home Phone

Membership & Add-ons

Membership Dues

Membership Name	Amount
MMA Dues 1-40 Employees	$575.00
MMA Dues 41-150 Employees	$875.00
MMA Dues 151-300 Employees	$1150.00
MMA Dues 301-600 Employees	$1750.00
MMA Dues 601-800 Employees	$2300.00
MMA Dues 801-900 Employees	$2875.00
MMA Dues 901-1500 Employees	$4025.00
MMA Dues 1501-3000 Employees	$5200.00
MMA Dues 3001-6000 Employees	$8500.00
MMA Dues 6001-7000 Employees	$17250.00
MMA Dues 7001+ Employees	$28750.00

Donation Name	Amount
MMA PAC Donation	$

Totals

Membership Dues:	$0.00
Discounts:	$0.00
Optional Subscriptions:	$0.00
Optional Donations:	$0.00
Optional Products:	$0.00
Taxes	$0.00
Credit Card Surcharge	$0.00
Total Payment:	$0.00

Payment Options

Select Payment Method

Accepted Card Types

Card Number

Expiration Date

Expiration Year

CCV

Save payment method for future use

Billing Information

Copy billing information from your user profile.

First Name

Last Name

Billing Address

City

State

Zip

Country

Terms and Conditions By submitting this form you are authorizing your credit card to be charged for the indicated amount. There are no refunds available. Please see our full terms and conditions page for further details. If you have any questions, please contact at . Thank you for choosing Miss. Manufacturers Association.

Organization Membership Application

Organization Basic Information

Organization Contact Information

Primary Contact

Alternate Contact

Membership & Add-ons

Totals

There is a % surcharge on credit card transactions to cover merchant fees.

The following fields are not valid:

Organization Membership Application

Organization Basic Information

Organization Contact Information

Primary Contact

Alternate Contact

Membership & Add-ons

Optional Donations

Totals

There is a % surcharge on credit card transactions to cover merchant fees.

The following fields are not valid: