Special page name & type will be: Special:Contact/affcomchapthorg
There is already Special:Contact/affcomusergroup on Meta-Wiki which handles application for Wikimedia user group status. This request is to create a form that will handle application for Chapter/Thematic org status.
The mailing list has already been created per T297622: Chapter-ThOrg-Applications mailing list request and the account tied to the mailing list will be created by @DNdubane_WMF on Meta-Wiki as well.