Maryland Association of Resources for Families and Youth

MARFY Resource Bank
Provider Registration Form

Maryland Association of Resources for Families and Youth
1517 S. Ritchie Highway, Suite 102
Arnold, MD 21012

Phone: 410-974-4901 Fax: 410-757-9530
email: mdavis@marfy.org

Use this form to register for provider status in the MARFY Resource Bank.

Participant Name:*
Organization Name:*
Email:*
Phone Number:*
Fax Number:*
Address:*
Types of Services Provided:*
Name of Program Administrator:*
Contact Phone Number:
Contact Email:
MARFY Member Fee:		One-time fee of $250.00
Non-member Providers:		Sign-up fee of $500.00 with Annual Dues of $250.00
		I will be paying by credit card
		I will be paying with a check through the mail.
		Please bill me at the address above.
Credit Card Number: (disclaimer)
Exp Date:
		VISA
		MasterCard
		Discover
V-code:
Name on Card:
Credit Card Billing Address: (if different from above)
Amount to be Paid:*
		Yes, I am a member.
		No, I am not a member.
		No, I am not a member but please send me info on how to become one.
Comments/Questions:
*Required fields.

Disclaimer: Please note that credit card information will not be processed at this time, but it is necessary to reserve registration if paying by credit card. Also note that this is not a secure website, so if you choose to submit credit card information, you are doing so at your own risk. If you would like to pay by credit card but do not want to enter your credit card information here, please fill out the rest of the form and either call or fax your credit card information in to MARFY at 410-974-4901, ext. 5. (continue)

Home : Public Policy : News : Upcoming Events :Member Services : Members Only : Contact Us

1517 Ritchie Hwy, Ste. 102 Arnold, MD 21012
Ph: 410-974-4901, Fx: 410-757-9530, Em: marfy@marfy.org