Affiliate Agency Form

Please fill out the information contained below or Click Here to download PDF and fax it back to us.

AGENCY AND CONTACT INFORMATION (Please provide the requested information.)

Instructions: Please fill out the requested information. If your agency's information is pre-populated, please verify that the information displayed is correct.
* Required fields are indicated with a red asterisk.
* Agency:
* CEO:
* Address:
* City, State, Zip:      
* Fax: * Telephone:
Toll Free: TDD Phone:
Web Site:

For purposes of voting in membership meetings please designate a primary contact:
Primary Contact
* First Name: * Last Name:
* E-mail:
It is imperative for NYAEMP to have an email address in order for your agency to receive full benefits of NYAEMP membership.