New Company Membership Application

Welcome to the New Company Membership Application for the Commonwealth Prevention Alliance!


Memberships are good from January through December of the current year if paid on or prior to October 31. NEW membership registrations made AFTER October 31 will begin January 1 of the following year.  If you have questions, email the Membership Committee prior to completing this form. 


Complete the following information.  All fields marked with an asterisk (*) are required.  


Select your membership level based on the number of sub-members you wish to enroll from your company/organization.

The Primary Contact is the only person who will receive notifications about your company membership including renewal and transaction emails.


If the Primary Contact is to receive CPA member benefits, be certain to include them in the sub-member list which follows on the next page of this application.



Create a Login Name and Password for your organization.  Passwords must be at least eight characters long, and contain at least one number.


This login information is unique to your company account.  Therefore, avoid using any personal login name and password. 


CPA is divided geographically into four regions.  Check the counties where your company provides services.   


From the list above, what is your CPA Region Number?