CEA Affiliate Profile

Organization Name*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary Point of Contact

Name*

First Last

Office Phone

Mobile Phone

Email*

Is the primary point of contact also the contact for invoicing?

Yes
No

Financial Point of Contact

Name*

First Last

Office Phone

Mobile Phone

Email*

Tell Us About Your Online Presence

Main Website Address

Facebook Page

Twitter Page

Additional Information

Would you like CEA to issue a press release announcing your organization's membership?

Yes
No

If applicable, would you like CEA to contribute to your organization’s blog?

Yes
No

Would you like to contribute to CEA’s blog?

Yes
No

Issues and States of Interest

What issues are most important to your organization?*

What states does your organization maintain operations or have interest?*

Please note, you may select All States as opposed to selecting every state if your organization maintains national operations.

Additions to CEA Distribution Lists

Please provide any additional individuals within your organization who should receive CEA updates. If there are more than five, you may send us an email with the individuals, their title, and email addresses.

Name

First Last

Email

Name

First Last

Email

Name

First Last

Email

Name

First Last

Email

Name

First Last

Email

Comments

This field is for validation purposes and should be left unchanged.

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CEA Affiliate Profile

Primary Point of Contact

Financial Point of Contact

Tell Us About Your Online Presence

Additional Information

Issues and States of Interest

Additions to CEA Distribution Lists