This name will be used in the MIN
CA's membership listing.
This should be the address of your center. If you provide a mailing address other than the physical address of your center, this address will need to be updated once your center is operational.
This should be the phone number of your center or agency and will be published in the MINCA membership public directory.
This will be the designated point person from your center for MINCA.
Enter a direct line or cell phone for the person you designated as your authorized agency representative. This will not be published in the MINCA public membership directory.
This should be the email for your authorized agency representative. It will not be published in the MINCA public membership listing.
You should have had contact with a Chapter representative prior to filling out this application and been given an understanding of which membership is best for your organization. Please contact the Chapter if you have any questions.