2013 OAESV Membership Form

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* 1. Member Name(s)

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* 2. Contact Name (if different than Member)

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* 3. Contact Title

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* 4. Mailing Address (Street, City, State, Zip)

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* 5. County

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* 6. Phone Number

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* 7. Fax Number

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* 8. Email Address

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* 9. May we use your name in print, broadcast, and electronic communications?

Yes

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* 10. Membership Type

Rape Crisis Centers & Programs (By selecting this option, please inform us of the contact names and info for individuals at your agency who should receive OAESV membership updates.)

Affiliate Organizations & Professionals (This membership type includes corporations, non-profit organizations, government agencies, private practices and other related agencies, including Forensic and Sexual Assault Nurse Examiner Units, Hospitals, Law Enforcement Agencies, Mental Health Agencies, other Victim-Service Agencies and Campuses. By selecting this option, please inform us of the contact names and info for individuals at your agency who should receive OAESV membership updates.)

Student

Ally/Advocate/Individual

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* 11. Membership Amount

$250/year - RCC or Affiliate with Annual budget > $500,000

$150/year - RCC or Affiliate with Annual budget $100,000 - $500,000

$90/year - RCC or Affiliate with Annual budget <$100,000

$15/year - Student

$30/year - Ally/Advocate/Individual

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* 12. Would you like to make an additional tax-deductible donation to OAESV? If so, please indicate the amount.

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* 13. Do you wish to make an additional contribution to the OAESV Public Policy Fund? If so, please indicate the amount.

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* 14. Would you like like more information about serving on one of OAESV’s Coalition Committees? (Check all that apply):

Standards Training

Public Policy

Mental Health Competencies

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* 15. Please indicate your region in Ohio

Southeast

Southwest

Central

Northwest

Northeast

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* 16. If paying by check...
Please make check out to Ohio Alliance to End Sexual Violence, then mail to:
Ohio Alliance to End Sexual Violence – Membership
526 Superior Avenue, Suite 1400
Cleveland, OH 44114

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* 1. Member Name(s)

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* 2. Contact Name (if different than Member)

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* 3. Contact Title

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* 4. Mailing Address (Street, City, State, Zip)

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* 5. County

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* 6. Phone Number

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* 7. Fax Number

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* 8. Email Address

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* 9. May we use your name in print, broadcast, and electronic communications?

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* 10. Membership Type

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* 11. Membership Amount

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* 12. Would you like to make an additional tax-deductible donation to OAESV? If so, please indicate the amount.

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* 13. Do you wish to make an additional contribution to the OAESV Public Policy Fund? If so, please indicate the amount.

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* 14. Would you like like more information about serving on one of OAESV’s Coalition Committees? (Check all that apply):

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* 15. Please indicate your region in Ohio

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* 16. If paying by check...Please make check out to Ohio Alliance to End Sexual Violence, then mail to:Ohio Alliance to End Sexual Violence – Membership526 Superior Avenue, Suite 1400Cleveland, OH 44114

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* 17. If paying online... click here, then click "Pay Now." (Remember to click "done" to finish the survey!)

* 16. If paying by check...
Please make check out to Ohio Alliance to End Sexual Violence, then mail to:
Ohio Alliance to End Sexual Violence – Membership
526 Superior Avenue, Suite 1400
Cleveland, OH 44114