Its CIVICUS

Membership Application Form

CIVICUS is an international alliance dedicated to strengthening citizen action and civil society throughout the world. Our vision is of a worldwide community of informed, inspired, committed citizens engaged in confronting the challenges facing humanity.

I / We would like: to apply for CIVICUS membership (for membership categories and fees, please see below)

 to renew my CIVICUS membership (for membership categories and fees, please see below)

 to support CIVICUS’ work with a donation of (please indicate $ or €)

Please complete the below chart, and mark with an “X” any items that we should not post on CIVICUS’ website:

ITEM / DETAILS / MARK WITH “X”
Name:
Position:
Organisation Name:
Postal address:
City:
Country:
Telephone:
Fax:
Email(s):
Website:

I / We have read and understand CIVICUS’ vision, mission and values and agree to support them.

SIGNED:

DATE:

CIVICUS MEMBERSHIP CATEGORIES
Please tick below the category for which you wish to apply. For further information on categories, please see the CIVICUS Membership policy available from the membership section of our website at Please contact us (see pg 2) if you cannot pay in US Dollars or Euros.

Citizen Organisation

Annual Income in US$ or Euros €Fee

(Estimated Conversion Rate: USD = 0.823460 EUR)

Group 1up to $75,000 / € 60,000 $50 / €40

Group 2$75,001 to $250,000 / €60,001 to €200,000$75 / €60

Group 3$250,001 to $500,000 / €200,001 to €400,000 $125 / €105

Group 4$500,001 to $1,000,000 / €400,001 to €800,000 $200 / €165

Group 5$1,000,001 to $3,000,000 / €800,001 to €2,500,000$300 / €250

Group 6$3,000,001 and over / €2,500,001 and over $500 / €410

Grant-making Organisation

Fee required is 0.1% of the organisation's annual grants

(Minimum Amount $500 / €410 and Maximum Amount $10,000 / €8,235).

Corporate Member $500 / €410

Individual MemberYouth Member (Individual Membership for ages 16-24)

 From a developing country $50 / €40 From a developing country $15 / €10

 From a developed country $100 / €80 From a developed country $25 / €20

I would like to pay for:

1 year

2 years

3 years Category Fee x number of years=Total amount

ORGANISATION DESCRIPTION: ______

___

What areas/fields is your organisation mainly involved in? Please mark with an “X” all fields that apply.

Civil Society Strengthening/Support / Health / Economic Development / Social Care & Services
Democracy and Governance / Environment / Housing & Homelessness / Religious Activities
Human Rights & Legal issues / Culture & Recreation / Professional Association/Union / General Charitable Purposes
International Development / Education & Research / Community development

Other:

METHOD OF PAYMENT: Please tick your preferred method.

CHEQUE PAYMENTS

* Please make your cheque payment made out to CIVICUS and enclose your cheque with the completed membership application form and send by post to:

 U.S. Dollars:

CIVICUS,1420 K Street NW, Suite 900.Washington, DC20005, USA.

 Euros:

CIVICUS, PO Box 933, Southdale, Johannesburg, 2135, South Africa.

WIRE TRANSFER PAYMENTS

* Please ensure that you reference your name or organisation name in the transaction, and that you make a total payment of the Membership Fee, plus any banking fees / charges.

Wire Transfer in U.S. Dollars:
PNC Bank, NA; Philadelphia, Pennsylvania (USA); Branch Code: 256506; Account Name: CIVICUS: World Alliance for Citizen Participation; Account number: 5300750957; ABAnumber: 031000053; Swift Code: PNCCUS33.

Wire Transfer in Euros:
First National Bank Ltd, Melville, South Africa; Branch Name: Melville Outlet; Branch Code: 256505; Account Name: CIVICUS: World Alliance for Citizen Participation – Membership Account; Account number: 62083227788; SWIFT Code: FIRNZAJJ950.

Wire transfer payment made on _ _/_ _/ _ _ _ _ (Month/Day/Year)

CREDIT CARD PAYMENT

* Please send this form with your credit card information by post, fax, or email to: Address CIVICUS, 1420 K Street NW, Suite 900.Washington, DC20005, USA / Fax+1 202 331 8774

Email: . (please include your authorisation in writing to charge your credit card).

 Credit Card:

Name as it appears on the credit card

Card type:  MasterCard VISA American Express

Card Number Expiry date

Currency and amount Signature of Card Holder

Amount to be paid: Membership fee $/€ Total payment $/€

MONEY GRAM & WESTERN UNION OPTIONS (money sent to U.S. only)

Please ensure that you reference your name or organisation name in the transaction, and that you make a total payment of the Membership Fee, plus any banking fees / charges.

Money GramWestern Union

Reference number:

Receiver’s name: Patricia Benton/CIVICUS: World Alliance for Citizen Participation

Receiver’s Address: 1420 K Street NW, Suite 900.Washington, DC 20005. Tel: 202-331-8518

Sender’s name:

Sender’s Residence:

Sender’s Phone Number:

Amount Sent:

Test Question (If applicable):

To help us estimate the effectiveness of our communications efforts, please provide a description of your organisation and indicate how you first learned about CIVICUS:

e-CIVICUS bulletin

 Referral from a CIVICUS Member
 Meeting with a member of CIVICUS staff (please include Programme or Department name)

 CIVICUS website

 Other (please state )
Please return this completed form to CIVICUS:

a) By Post or Fax (USA):CIVICUS, 1112 1420 K Street NW, Suite 900.Washington, DC 20005. USA

Fax: +1 202 331 8774 / Telephone: +1 202 331 8518

b) By Post or Fax (RSA):CIVICUS, PO Box 933, Southdale, Johannesburg, 2135, South Africa

Fax +27 11 833 7997 / Telephone: +27 11 833 7997

c) By e-mail:

1

When returning this form, please assist us in keeping up-to-date records about your organisation’s work by sending us a copy of your annual report, or any other programmatic information available by post or fax (RSA Office), or by email.