MembershipApplication



	COLLIER COUNTY NON-DISCRIMINATION COALITION P.O. BOX 351, NAPLES, FL 34106 (239) 436-7999 info@CollierCoalition.org Please fill out the following information on your organizational letterhead (if applicable). Send the application and annual dues to the above address. Organization Application The (name of the organization)__________________________________________________________ is pleased to join the Collier County Non-Discrimination Coalition. We affirm the Coalition Mission Statement and authorize our organization name to be included in the Coalition. Annual Dues for Organizations: If your organization has a paid staff member please remit $100. If your organization operates on a volunteer basis please remit $50. Dues are renewable by March 31st of each year. Our Representative is: ____________________________________________ Phone # _______________________________________ FAX # _________________________________________ Email: ________________________________________________ Please submit your email address for important organizational materials & quarterly newsletters. Your email address will remain confidential. Our Alternate Representative is: _________________________________________________ Phone # ________________________________________ FAX # _________________________________________ Email: _________________________________________ __________________________________ _______________ Authorized Signature & Title Date ---------------------------------------------------------------------------------------------------------------------------------- Individual Application I, _____________________________________________ am pleased to join the Collier County Non-Discrimination Coalition. I affirm the Coalition Mission Statement and authorize my name to be included in the Coalition. Annual Dues for Individuals: Individual membership dues - please remit $25. Dues are renewable by March 31st of each year. Name: _________________________________________ Phone # _______________________________________ FAX # _________________________________________ Email: _________________________________________ Please submit your email address for important organizational materials & quarterly newsletters. Your email address will remain confidential. _____________________________________________________ _______________ Signature Date