Please complete this application if you would like to be considered for ACT's Membership Assistance Subsidy, which offers financial assistance for annual membership fees. Financial assistance may take the form of a full or partial subsidy of the annual membership fee. To maximize the likelihood of acceptance, please provide as much detail as possible.

Please allow up to 31 days for review of your application.

Please note that the Membership Assistance Subsidy is a pilot program that awards financial assistance for one year of ACT membership. Financial assistance for future membership years will require separate future applications.

Assistance in available for incoming organizations only.

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* 1. Organization Name (if self-employed, write your name and/or DBA)

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* 2. Organization's primary address:

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* 3. List any additional office locations (city, state):

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* 4. Organization's website:

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* 5. What professional sector is your organization in?

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* 6. Total number of employees:

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* 7. Total number of employees engaged in TDM activities (programs, operations, admin, etc.):

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* 8. Is the organization currently a member of any other professional organizations (e.g., American Planning Association)?

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* 9. Is your organization certified as a disadvantaged business enterprise (DBE)? Note that you may be asked for proof if you indicate Yes.

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* 10. How will your organization support belonging and engagement within ACT's membership? Check all that apply.

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* 11. Please describe your need for financial assistance for ACT membership:

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* 12. What value would ACT membership bring to you or your organization? (e.g., organization would provide unique subject matter expertise or experience to the TDM community; organization would increase geographic diversity of ACT's membership; etc.)

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* 13. Assuming no financial barriers, how many individuals would your organization include in its membership to ACT? If the membership would be for you as a self-employed member or retiree, answer "1."

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* 14. What total annual membership fee would be financially feasible for you or your organization?

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* 15. If an individual referred you to ACT, please tell us who:

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* 16. Name of individual submitting form:

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* 18. Phone number

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Thank you for your interest in ACT membership. Please allow up to 31 days for review of your application. The Membership Committee will review your application and respond to you.