IMIA Proposal Submission

IMIA Proposal Submission Form
Your Name	First Last

Your Address	Street Address Street Address Line 2 City Region Postal / Zip Code Country

Contact Number	### - ### - ####

Email

If you have a PayPal account, please enter that email
Company/Organization Name

Company/ Organization Address	Street Address Street Address Line 2 City Region Postal / Zip Code Country

Business Phone	### - ### - ####

Attach Proposal

You will be billed the 25.00 proposal fee, using your email listed above