Associate Membership Application

InterHab is thrilled to have your interest as an Associate Member. Please fill out the form below to submit your application for membership. InterHab staff will reach out with additional questions as needed. Membership dues are $750 annually.

Business Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Website(Required)

Primary Contact Name(Required)

Primary Contact Title(Required)

Primary Contact Email(Required)

Secondary Contact Name

Secondary Contact Title

Secondary Contact Email

Corporate Status(Required)

Please describe(Required)

Does your agency serve individuals with developmental disabilities?(Required)

Does your agency serve individuals with other disabilities?(Required)

Please use the box below to enter your mission statement:(Required)

Should your organization begin providing direct services during this calendar year, dues shall be calculated and paid based on an estimate of salaries and wages which will be paid in the first full year of service, subject to a refund for over-estimated dues, or a surcharge in the following year to compensate the association for under-estimated dues.