Civics Coalition Membership Form

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Name*

PrefixFirst NameLast Name

I am committing to joining the coalition...*

As an IndividualAs an individual, and would like the Indiana Bar Foundation to reach out to my organization for organizational membershipOn behalf of my organization, as my organization has already committed as an organizational member

Email*

example@example.com

Cell Phone Number*

Employer*

Office Phone Number

Personal Address*

Street Address

Street Address Line 2

CityState

Zip Code

Please select the committee(s) of which you would like to be a part

Civic Advocacy CommitteeCivic Education CommitteeCivic Health Committee

Please select all the Committees that interest you (or members of your organization)

Civic Advocacy CommitteeCivic Education CommitteeCivic Health Committee

Would you like to make an individual contribution supporting the Indiana Civics Coalition?

YesNo

Civics Coalition Membership

Individual Contribution$50.00

Quantity

Individual Contribution$75.00

Quantity

Individual Contribution$100.00

Quantity

Individual Contribution$150.00

Quantity

Individual Contribution$200.00

Quantity

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

For questions or concerns regarding organizational outreach, sponsorship, or partnership, please contact Kim Berry (Kberry@inbarfoundation.org).

I am the Contact Person at my organization for the Indiana Civics Coalition*

YesNo

Organization/Company Name*

Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Person*

First NameLast Name

Email of Contact*

example@example.com

Contact Phone Number*

Area CodePhone Number

Please list any additional points of contact at the organization

Indiana Civics Coalition Membership