Council Level Membership Request

Investment: $1,192/year
Users: 8 ($149 each add'l user)

Membership in the Association of Diversity Councils is available to diversity councils of organizations based in the United States and Canada only.

This information is for our internal use only.

First Name*
Last Name*
Position/Title*	Position/title within your organization
Organization Name*
Address*
City*
State*	Select US/Canada state or province
ZIP/Postal Code*
Country*
Phone*	US and Canadian format: xxx-xxx-xxxx.
Email Address*	Our primary contact method. For internal use only.

# of Users*	How many users of DiversityCouncil.com are you requesting? minimum 8.
Size of Coucil*	How many members in your diversity council/group?
Size of Organization*	Total number of employees in your organization
Age of Council
Council Budget	Does your diversity council have a budget?
Biggest Challenge	What is your council's biggest challenge
Industry*
Need PO	Select Yes if your organization requires a purchase order or invoice prior to payment.
Pay by Check	Select Yes if you would like to pay by check.
Credit Card Type
Billing Name	Name as it appears on credit card
Credit Card Number	Numbers only, no spaces or hyphens
Credit Card Expiry	/
Credit Card Security Code	Find the CVN for MasterCard or Visa Find the CVN for AMEX
Expectations/Comments	What are you hoping to achieve by membership in the ADC
Terms & Conditions*	View terms and conditions of membership

	Contact Us
	If you prefer to speak with one of our representatives, feel free to contact us between 9:00 A.M. and 5:00 P.M., Monday-Friday (US Eastern time, except holidays). Association of Diversity Councils 312 West First Street Suite 500 Sanford, FL 32771 Toll free: 866-220-6370 Email: info@diversitycouncil.com

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