Partner Form – NYSALAS

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Advocacy, Collaboration, and Empowerment

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Partners
Membership
Events
Scholarship
Job Board

Partnership/Business Information

Partnership/Business Name(Required)

Email(Required)

Name(Required)

Main Contact First Name Main Contact Last Name

Main Contact Email(Required)

Mailing Address(Required)

City State Zip Code

Preferred Phone Number(Required)

Can this phone receive text messages?(Required)

Yes

No

Website

X (Twitter)

Facebook

Membership Type(Required)

New

Renewal

Membership Region (Check One)(Required)

Region 1: Long Island

Region 2: New York City

Region 3: Lower-Hudson

Region 4: Mid-Hudson

Region 5: Capital District

Region 6: Syracuse

Region 7: Rochester

Region 8: Western New York

Partnership/Business Membership Levels(Required)

Founding Partner - $10,000.00

Diamond - $7,000

Platinum - $5,000

Gold - $3,000

Donations

$100.00

$250.00

$500.00

$1,000.00

Total

Payment Method(Required)

Credit Card

Check

Credit Card

Check Number:

Please make checks payable to NYSALAS and mail to:
Dr. Carlos Cotto, Jr
240 State Street, Apt #405
Schenectady, NY 12305

Would you like to be contacted regarding sponsorship of NYSALAS special & regional events?(Required)

Yes

No

For additional support or further information, please email info@nyslas.org