Test Reg Form

Organization Name

Executive Director Name

Address Line 1

Address Line 2

State

Zip Code

Phone Number

Email Address

Organization Website URL

Tax ID

501c(3)? Organization is a registered 501c(3)

Please upload the previous (2) years of Form 990 (PDF)

990 (1)

990 (2)

Please upload Last Annual Report/Audit (PDF)

Annual Budget Size

Number of Employees

Number of Board Members

Upload Agency Brochure (PDF)

Programs and Services offered

Do you provide services to people living with epilepsy?yesno

Do you provide services to people not living with epilepsy?yesno

In applying to become a Member Organization of Epilepsy Alliance America, the above-name organization, confirms that it meets the following criteria:

Activities and goals of the organization are focused on supporting people affected by epilepsy and/or seizure disorders;
The organization is formally organized with a written constitution and/or Bylaws as a 501c3 organization;
The organization has a Constitution and/or Bylaws which do not conflict with that of the Epilepsy Alliance America.

Authorized Official Name (First & Last)

Authorized Official Signature (Please Initial)

Authorized Official Title

Statement of Intent

Please leave this field empty. Please leave this field empty.