Please Note: Adobe Acrobat is required to be able to use the 'Submit…

Please Note: Adobe Acrobat is required to be able to use the 'Submit by Email' button. If you do not have this
                                                                                                                 Submit by Email   Print Form
software, please print the completed form and fax it to the Philanthropy Center at (407) 975-6419.




                     INDIVIDUAL MEMBERSHIP APPLICATION
                     In conformance with the Philanthropy Center's Privacy Policy, we do not share
                     information in our database with anyone.

                     General Information:
                     Name:
                     *Organization (if applicable):
                     Address:
                     City:                                                                           County:
                     State:                                                                            Zip:
                     Telephone:
                     Email address:                                                                     FAX:
                     * If you'd like your organization name included on a name tag when you attend our workshops,
                     please include the organization name.

                                                     Membership Categories & Fees
                  Nonprofit Organization Memberships
                  Membership dues for nonprofit organizations are based on the organization's operating budget
                  as follows:

                               Annual budget: less than $100,000                                        $125
                               Annual budget: $100,001 - $500,000                                       $200
                               Annual budget: $500,001 - $1,000,000                                     $225
                               Annual budget: $1,000,001 - $2,000,000                                   $325
                               Annual budget: $2,000,001 - $3,000,000                                   $425
                               Annual budget: $3,000,001 - $4,000,000                                   $550
                               Annual budget: $4,000,001 - $5,000,000                                   $600
                               Annual budget: over $5 million                                           $700

                  Government Department or Agency Membership
                         Annual budget: less than $1 million                                            $350
                         Annual budget: $1 million and over                                             $750

                  Single Memberships
                           Individual                                                                   $150




                                                                                  1
  Payment by check (payable to Rollins College):       Amount enclosed:

  Payment by credit card:    Charge my:        Visa®        MasterCard®
  Name on card:

  Card number:

  Billing
  address:
  V-code (A 3-digit number found on the back of the credit card
  on the signature line):

  Expiration date:              Signature:


Mail form and payment to:       Philanthropy & Nonprofit Leadership Center
                                Rollins College
                                1000 Holt Avenue ~ 2755
                                Winter Park, FL 32789-4499

If you have questions, please contact us at 407-975-6414 or pnlc@rollins.edu. Forms may be faxed
to 407-975-6419. We encourage you to refer to our Web site for the most current information,
forms, and upcoming events: http://www.pnlc.rollins.edu.




                                              2