Membership Enrollment Application


	2. AGENCY INFORMATION
	Agency Name*
	Executive Contact*
	Title:
	Email Address
	Membership Contact*
	Title:
	Email Address
	Technical Contact*
	Title:
	Email Address
	Billing Contact*
	Title
	Email Address
	Address*
	City*
	State*
	Zip*
	Telephone
	Fax
	General Email Address*
	Website Address
	Employer ID Number [from IRS 501(c)3 letter]*

1. MEMBERSHIP STATUS


	1. MEMBERSHIP STATUS
	Please indicate whether you are a new member or renewing your existing NPower membership. New Member Membership Renewal


	3. AGENCY FOCUS
	What is your organization's area of focus? Arts & Culture Charitable Foundation Education Environment Health & Human Services Housing/Community Development Social/Legal Advocacy Other: Other Value
	Please tell us briefly about your organization's mission:*


	4. MEMBERSHIP DUES Based on your organization's current operating budget, check the appropriate box below to indicate your Membership dues. (If this figure somehow misrepresents your organization’s financial situation – e.g., you are the regional office of a national nonprofit organization or you are part of a larger, locally based organization but that organization is not joining NPower Indiana – please give us a call.)
	Over $5 Million............................$450 $1 Million - $5 Million.................$350 $250,000 - $1 Million.................$250 Up to $250,000...................$150


	5. PAYMENT
	Please sign us up as members of NPower IN* Please invoice our organization for the amount of membership dues indicated in Section 4.