MEMBERSHIP APPLICATION

             Name of Agency/

          Individual:          *

              Mailing Address:      *

                                  City:   *  State:    *

                          Zip Code:    *

            Physical Address:     

                                  City:   State:  

                           Zip Code:  

How did you hear about us?   *

  Which address would you

       like listed in the online

            Member Directory?     Mailing AddressPhysical Address*

                       Telephone:  *

               Toll Free Phone: 

                                  Fax: 

                                Email: 

                           Website: 

                              Status:  Individual Currently Establishing a NonprofitPrivate FoundationPublic Charity 501 (c) (3)Public Charity 501 (other) Not for Profit Educational Institution Government Faith-Based For Profit Business *

                  Contact Name:  *

(To be listed in the online member directory)

Director/President/ Business

      Owner:  

            Additional Contact: 

Please describe your organization or business as you would like it to appear in the Member Directory. Please keep this description below 1000 characters. *

Please choose your Membership Level:

(click here for a description of each level)

--Select-- Capacity Builders (Nonprofit, government, faith based) - $75 annually Associate Members (Individuals/Public )- $75 annually Sustaining Members - Nonprofit - $175 annually Sustaining Members - For Profit - $175 annually Leadership Circle - Nonprofit - $250 annually Leadership Circle - For Profit - $250 annually *

Please check one category that best describes your agency: --Select-- Animals Arts and Culture Children and Youth Community Development Domestic Violence Economic Development Education and Literacy Environment and Natural Resources Families and Elders Foundation Funding Health and Mental Health Housing Individual Social Services Technology and Communications Other (please explain) -*

                                Other:  

Nonprofit organizations please fill out the following:

        Number of Paid  Staff:

       Number of Volunteers:

                  Date Founded:  

                 Annual Budget:  

                       Funded By:   Grants Membership Fees Fee for ServicesDonationsSale of MerchandiseFunding Events Endowment/Foundation Other

                              Other:  

(Use ctrl-click to choose more than one option)

         Method of payment:   --Select-- CheckCredit Card * 

For payment instructions and to complete your registration,

click the 'Submit' button