Member - Long Island Association, Inc., NY

Member Application

Thank you for your interest in joining the Long Island Association. We will contact you shortly to discuss your application and to review the membership options that are available. If you would like to contact us directly, please call (631) 493-3000 or email info@longislandassociation.org.
Business Information

Company Name: *

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Phone: *

Website: *

Email: *

Business Description (200 char max):

Directory Category:

Employees:

Full-time Part-time

Comments / Questions:

Physical Address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Mailing Address

Same as physical address

Line 1: *

Line 2:

City: *

State: *

Postal Code: *

Country: *

Primary Contact Information

First Name: *

Last Name: *

Title: *

Phone: *

Email: *

Contact Preference:

Email Phone

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Billing Contact Information

Same as Primary Contact

First Name: *

Last Name: *

Title: *

Phone: *

Email: *

Contact Preference:

Email Phone

Address

Same as Member Address

Line 1: *

Line 2

City: *

State: *

Postal Code: *

Country: *

Membership Options

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Member Application

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