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

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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