FGBC Green Local Government Certification Registration Form

Submit this form to register for the FGBC Green Local Government designation. It represents your commitment to pursue the certification requirements.

Upon registration, FGBC will assign a Project Evaluator to answer questions regarding the certification process, criteria and required submittals.

A minimum deposit of $500 is required with registration, or you may pay the full application fee when registering.

For more information visit the FGBC website.

Government Name *

Main Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Population *

Coordinator Name *

First Name Last Name

Coordinator Dept. *

Coordinator Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Coordinator Phone Number *

- Area Code Phone Number

Coordinator E-mail *

List pertinent Local Government Decision makers involved.

Coordinator Department Manager *

First Name Last Name

Title *

Phone Number *

- Area Code Phone Number

E-mail *

City or County Administrator *

First Name Last Name

Title *

Phone Number *

- Area Code Phone Number

E-mail *

Mayor or Highest Ranking Elected Official *

First Name Last Name

Title *

Phone Number *

- Area Code Phone Number

E-mail *

Version *

Fees

Registration Fee $ 500.00

Total Certification Fee - Population Up to 20,000 $ 3,000.00

Total Certification Fee - Population 20,000 - 99,999 $ 4,000.00

Total Certification Fee - Population 100,000 - 200,000 $ 5,000.00

Total Certification Fee - Population Over 200,000 $ 6,000.00

Final Application Fee - Balance Due $ 2,500.00

Final Application Fee - Balance Due $ 3,500.00

Final Application Fee - Balance Due $ 4,500.00

Final Application Fee - Balance Due $ 5,500.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

By submitting this registration form, I attest to the following:

I have read the FGBC Green Local Government Designation Standard and will abide by its policies.
By registering, the local government agrees to submit the necessary documentation for all credit points claimed in the final application submittal.
I understand that failure to earn a designation will not be grounds for refunding of the deposit.
I have the contractural authority to represent the local government.