NEW MEMBER APPLICATION
Primary Contact Information
First Name
MI
Last Name
Work Title
Work Phone
Email
Organization Information
Please select your organization's annual operation budget
Please select...
Under $50,000
$50,000 - $99,999
$100,000 - $249,999
$250,000 - $499,999
$500,000 - $999,999
$1,000,000 - $2,499,999
$2,500,000 - $4,999,999
$5,000,000 - $7,499,999
$7,500,000 or higher
Organization Legal Name
Organization Acronym
Organization Alias
Street Address
City
State
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Alabama
Alaska
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(Not USA)
Zip
County
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Albany County
Allegany County
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Chenango County
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Ulster County
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Wayne County
Westchester County
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Yates County
Website
Fax
Notes
Mission
Services
Please select...
Advocacy
Arts
Capacity-building
Case Management
Children
Civic Engagement
Community Education
Court Accompaniment
Economic Development
Education
English Classes
Faith-Based
Families
Gender-Based Violence
Healthcare
Housing
Human Trafficking
Integration
Labor
Language Services
Leadership Development
Legal Services
Media
Nutrition
Policy
Public Benefits
Research
Senior Services
Small Businesses
Social Services
Women
Workforce Development
Youth
Geographic Area
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Capital District
Central New York
Finger Lakes
Hudson Valley
Long Island
Mohawk Valley
New York City
North Country
Southern Tier
Western New York
Immigrant Communities Served
Please select...
African
API
Caribbean
European
Latin
MENASA (Middle East/North African)
South Asian
Languages Spoken by Staff
Please select...
American Sign Language
Arabic
Bengali
Bosnian
Bulgarian
Chinese (Cantonese)
Chinese (Mandarin)
Czech
Dutch
English
Farsi
French
French Creole
German
Greek
Haitian- Creole
Hebrew
Hindi
Indonesian
Italian
Japanese
Kannada
Korean
Lithuanian
Macedonian
Malay
Malayalam
Mandingo
Mandinka
Panjabi
Persian
Polish
Portuguese
Romani
Romanian
Russian
Serbo- Croatian
Somali
Spanish
Tagalog
Tamil
Telugu
Thai
Turkish
Twi
Ukrainian
Urdu
Vietnamese
Wolof
Immigrant attorney on staff
Please select...
Yes
No
DOJ-accredited rep on staff
Please select...
Yes
No
Accept referrals
Please select...
Yes
No
Expectations of membership in the NYIC
Additional Information
Organization Reference
Organization Name
Contact Name
Phone
Email
Upload of 501(c)3 tax exempt letter (or Fiscal Sponsorship letter)