Affiliate Member Signup

Thank you for your interest in becoming a member of the NYS County Highway Superintendents Association.

Choose the membership starting period closest to the current date. The membership period is one year from the start date (January 1 or July 1).

Membership is organization based -- all employees will inherit membership privileges through the business. You will need to complete contact details on behalf of the organization as well as yourself.

If you are a current member, you MUST login before completing this form.

Join the NYSCHSA

Affiliate Membership

Affiliate Membership - $ 300.00

- none -

Total Amount

On Behalf Of Organization

Organization Name *

Phone (Main) *

Email (Main) *

Street Address *

City *

Postal Code *

Country *

State / Province *

Website

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

Check Availability
Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Password

Confirm Password

Provide a password for the new account in both fields.

Primary Contact Details

First Name

Last Name

Job Title

Address

Address 2

City

Country

State

Zip Code

Phone

Email *

Website

Tag(s)

Credit Card Information

Card Type

Card Number *

Security Code *

Expiration Date *

My billing address is the same as above

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *