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AIA Long Island Chapter

499 Jericho Turnpike, Mineola, NY 11501

Tel: 516-294-0971 | Fax: 516-294-0973

Request Form For Referral Listings !

Notes:
All requests will be verified by Chapter Office before listing at the web site.
This form is for AIA Long Island Chapter Members Only !

Fee Information:
Initial Cost For One Category: $50.00 | Cost For Each Additional Category: $15.00 | Cost For Information Change: $75.00

* = required fields

Company Name :*

Address :*

City :*

State / Zip :*
Telephone Number :*

Fax Number :*

Contact Name :*

E Mail Address :*

Listing(s) Area of Interest : (Select all that apply)
Residential - Single Family    Residential - Multi Family    Residential - Remodeling

Residential - Interiors    Retail Facilities    Commercial Office Facilities

Educational Facilities    Religious Facilities    Hospitality - Food & Entertainment Facilities

Retirement Communities/Assisted Living Facilities    Environmental Graphics/Signage Design

Commercial Interiors    Corporate Interiors

Comments : (will not be added with listing)

AIA Long Island Chapter Member :*
Yes     No

Please check all that apply below :
New Addition(s) To Listings       Update(s) To Existing Listings

Payment Will Be By :*

Cash Check Credit Card

Credit Card Information :

Name on Card :

Credit Card Type :

Expiration Date :

Credit Card Number : Select option below.

Select One Below :

Please call me to confirm order, and to receive my credit card number. I will call myself to confirm order, and to give you my credit card number.

Fee Information:
Initial Cost For One Category: $50.00 | Cost For Each Additional Category: $15.00 | Cost For Information Change: $75.00

To continue, click on the "SUBMIT" button below.

Questions or problems with this form, call chapter office for assistance.