Organizational Membership Form 2017

Become a member-partner of the FM Coalition!

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* 1. Organization Information

Name:

Address:

City;

State:

Zip:

Phone:

Fax:

Website:

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* 2. Primary Contact

Name:

Title/Program:

Email:

Home Address:

City:

State:

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* 3. Authorized Voting Delegate from your Organization

Delegate 1 Name:

Delegate 1 Email:

Delegate 2 Name:

Delegate 2 Email:

Delegate 3 Name:

Delegate 3 Email:

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* 4. List primary services provided:

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* 5. Organizational Membership Fee (one vote per organization)

$100 Annual Membership Fee

Our organization would like to make a donation in addition to the membership fee
($100 + $_______) and will be included with our payment.

Our organization is not allowed by law to pay for membership and requests a fee waiver.

Our organization requests a reduction or waiver of the membership fee due to financial concerns.
(No one is refused membership due to inability to pay.)

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* 6. Payment option:

Payment by credit card (fastest and easiest: go to FMhomeless.org and chose the 'donate' option)

The check in in the mail.

Bill me.

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* 7. My organization supports the mission of the FM Coalition for Homeless Persons to work in partnership to achieve permanent solutions to prevent, reduce, and end homelessness.

On behalf of my organization, I agree to the above.

Verification/e-signature: