Agency Membership Application

Please complete the following information completely so that we can review your Agency Membership Application. Starred items* are required.

Agency Name(*)
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First Name(*)
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Last Name(*)
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Title(*)
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Address(*)
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City(*)
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State(*)
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Zip Code(*)
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Phone(*)
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Fax
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Email Address(*)
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Website
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Federal EIN(*)
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Incorporation Date(*)
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Incorporation State(*)
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Mission Statement(*)
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What will your agency do to promote the growth of Community Shares?(*)
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By submitting this application, my agency is applying for membership in Community Shares Utah. If accepted, we agree to be bound by Community Shares Membership Agreement, Bylaws, Policies, and Procedures.

(*)

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