HUMAN SERVICES ADVISORY COUNCIL, INC
P.O. Box 894 Council Bluffs, Iowa 51502
Email address *
AGENCY MEMBERSHIP APPLICATION
Membership is $50 per organization for a year (January 1st - December 31st) and is due at the time of application. Payment may be made by check, payable to the Human Services Advisory Council (HSAC) and mailed to the address noted above. Online payment may be made via PayPal. A link will be provided upon submitting this application.
Name of Agency/Organization *
Address *
City *
State *
Zip Code *
Phone *
Fax
Email Address *
Agency Website
Name and e-mail address of Representative (this person will receive all e-mail communication)
Name(s) and emails address(es) of Other Attendees from the Agency who will be added to our e-mail list-serve
All contact information will be posted on the HSAC website unless otherwise specified. If there is information you do not want posted, please indicate here:
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