| Organization Name |
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| Address |
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| Telephone Number |
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| Fax Number |
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| Website Address |
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| Name of ICA Housing Contact |
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| Email Address of ICA Housing Contact |
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| Year Organization Founded |
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| ICA Global Status |
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| If B, Name of Organization |
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| Brief Description of Organization |
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| Number of Members |
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| Number of Housing Members, if known |
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| Number of Housing Units, if known |
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| Types of Members |
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| Source of Finance |
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Please note if you checked B. for ICA Global Status you will need to provide a letter from this ICA Member stating their approval of your representation in ICA Housing.
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