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GHSA Associate Membership Application - Credit Card Payment ONLY

Select Associate Membership Price *

$1,000 - Corporate (4+ employees)

$550 - Non-Profit (must provide IRS letter indicating 501(c)(3) tax exempt status)

$450 - Small Business (1-3 employees, including individual consultants)

$250 - Emeritus (former GRs/Coordinators)

Upload your IRS letter or tax-exempt certificate

Payment

For any financial questions or concerns, please contact Lisa Wagner at lwagner2@ghsa.org or 202-580-7929.

If your application is rejected, your dues payment will be refunded.

Please select the payment method your organization plans on providing for membership dues. GHSA bylaws specify that Associate Member dues be assessed at the time of application. Your organization's application will not be considered for Board approval until payment is received.

If your organization only provides check or ACH payments, please contact Lisa Wagner at lwagner2@ghsa.org or 202-580-7929 for assistance. *

Credit Card (payment details to be provided on next screen)

IMPORTANT INFORMATION: PLEASE READ BEFORE COMPLETING APPLICATION!

If you work for a State Highway Safety Office or existing GHSA Associate Member, you are already considered a member of GHSA.

GHSA Associate Members must agree to support the goals and objectives of GHSA and may not vote on Association policies. Associate Member dues support the general purposes of GHSA, including publications, training and research.

The GHSA Executive Board reviews all Associate Member applications quarterly (March, June, August/September, December). You will be notified after the next Board Meeting whether your application has been accepted. Associate Membership does not imply GHSA endorsement or grant permission to use the GHSA logo.

Applications reviewed at the June, August/September and December meetings include membership through the fiscal year, which ends on June 30. Applications approved at the March meeting will be approved for the remainder of the fiscal year and the following fiscal year, which begins on July 1.

To be considered at GHSA's Executive Board Meeting in June, your application and payment must be received on or before May 20, 2024.

Organizational Information

Organization *

Street Address *

Address Line 2

City *

State/Province *

Zip Code *

Phone Number *

Email Address *

Website *

Social Media Handle: Twitter *

Social Media Handle: Facebook *

Social Media Handle: LinkedIn *

Which of the following categories best describes your organization? Please select ONE of following options below. If you believe your organization falls under more than one category or under a different category not listed, please email Kerry Chausmer at kchausmer@ghsa.org for further assistance. *

Automotive Industry - Automakers or organizations who represent them.

Enforcement - Organizations or individuals from or representing the law enforcement community.

Insurance Industry - Insurance providers or organizations who represent them.

Issue Advocacy - Organizations or individuals who advocate for various traffic safety issues at the local, state, or national level.

Law Firm - Attorneys who represent individuals who have been injured in traffic crashes.

PR/Communications/Marketing - Organizations or individuals who conduct public relations, communications or marketing efforts to advance traffic safety.

Product Providers - Companies that provide specific products and/or services such as ignition interlocks, grants management platforms, or traffic records software.

Researchers & Consultants - Organizations or individuals who conduct research or consult on traffic safety issues.

Primary Contact Information

First Name *

Last Name *

Title *

Street Address *

Address Line 2

City *

State/Province *

Zip Code *

Phone Number *

Email Address *

How did you hear about GHSA? *

0/500 words

Why are you interested in becoming a member of GHSA? What are your expectations of membership? *

0/500 words

Web Listing

GHSA maintains a web page with the logos and descriptions of all our Associate Members.

Please upload your logo for display on our website.

Please provide a brief description of you/your organization for our website. *

0/500 words