HUMAN SERVICES ADVISORY COUNCIL, INC
P.O. Box 894 Council Bluffs, Iowa 51502
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AGENCY MEMBERSHIP APPLICATION
Membership is $50 and should be processed with this application. Online payment will be processed when you submit this application.
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City *
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Zip Code *
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Fax
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Email Address *
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Agency Website
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Name and e-mail address of Representative (this person will receive all e-mail communication)
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Name(s) and emails address(es) of Other Attendees from the Agency who will be added to our e-mail list-serve
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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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