CIVICUS MEMBERSHIP APPLICATION FORM CIVICUS IS AN INTERNATIONAL ALLIANCE

PART A: Applicant Details

Organisation Name:

Mailing Address:

City:

Postal Code:

Country:

Telephone No:

Fax:

Email:

Website:

Organisation description:

(300 words max in English or 150 in English and 150 in your country’s language)

Type of Organisation/ Profession:

Cultural group/organisation

Development practioners

Faith-based organisation

Grass-roots organisation

International non-governmental organisation

Media agency

Network and/or alliance (national, regional or international)
Non-Governmental organisation

Philanthropic / Funding organisation

Research institute / Think tank

Sports Association

Trade or professional association (inc trade unions)

University / Educational establishment

Volunteer sending organisation

Individual Member

Publish?

Can your details be made public in CIVICUS Membership Directory?

Yes, we would appreciate our organisation’s details published in the Membership Directory.

No, our organisation’s details should remain confidential and NOT published in the Membership Directory.

PART B : Key Contact People for CIVICUS (Only for Institutional Membership)

Name(s)

Job Title(s):

E-mail:

1

2

3

4

5

6

PART C: Referral

Heard About CIVICUS?

Current CIVICUS Member

CIVICUS Staff Member

CIVICUS Website

e-CIVICUS

Social Network

Direct Mailing

Media

Event/Conference

Name/Who/Where referred?

Organisation:

Date:

PART D: Activity Areas

Accountability

Housing

Agriculture/Farming/Fishing/Forestry

Human rights and social justice

Animal Welfare/Rights

Humanitarian relief

Arts and Culture

Indigenous peoples (inc land rights)

Children/Youth

Information Communication Technology

Civic Participation and Volunteerism

International institutions (UN, IFIs etc)

Civil Society Strengthening

Law and legal reform

Climate Change

Media/journalism/press freedom (inc alt & community media)

Conflict Resolution/Peace/Security

Men/boys

Disability

Microfinance

Economics/Trade

Poverty/MDGs

Education (inc ECCD) and skills development

Religion

Energy/Extractive industries

Seniors

Environment/Conservation

Slavery/human trafficking

Ethnicity/Race

Sport

Food/Nutrition

Sustainable Development

Forced Migration/Refugees

Technology

Gender and Sexuality

Volunteerism

Globalisation

Water/Sanitation

Governance and Transparency (inc local governance)

Women/girls

Health (inc addiction, excl HIV/AIDS)

Workers rights (inc sex workers)

HIV/AIDS

Geographical Focus

Single country

Specify:

Multi country Africa region

Specify:

Multi country Americas Region

Specify:

Multi country Asia Region

Specify:

Multi-country Europe Region

Specify:

Multi Country Oceania Region

Specify:

Global (multiple countries in multiple regions)

Specify:

Preferred Language of Communication

English

French

Spanish

Portuguese

Other Please specify:

PART E: Interest in CIVICUS

How would the organisation/you would like to participate in CIVICUS activities

[Please tick the appropriate option(s)]

Undertake activities to accomplish CIVICUS Mission, Vision and Values

Participate in CIVICUS events

Participate in The Civil Society Index (CSI) Programme

Participate in The Civil Society Watch (CSW) Programme

Participatory Governance (PG) Programme

Apply to be a CIVICUS Membership Country/Regional Representative – on a Volunteer basis

Apply to a be part of the CIVICUS Affinity Group of National Associations
Adopt the International Non-Governmental Organisations Accountability Charter (IANGO)

Contribute with sponsorship to various CIVICUS activities and events

..................................................................................................... [others] 

..................................................................................................... [others] 

................................................................................................. [others] 

PART F: CIVICUS MEMBERSHIP CATEGORIES

Please select the category you wish to apply for. For further information on categories, please see the CIVICUS Membership policy available from the membership section of our website at www.civicus.org

Citizen Organisation

Grant-making Organisation
Fee required is 0.1% of the organisation's annual grants
(Min. amount $500 and max. amount $10,000).

Individual Member Youth Member (Individual Membership for ages 16-24)
From a developing country $50 From a developing country $15

From a developed country $100 From a developed country $25

Please indicate your age:      

I would like to pay for: 1 year 2 years 3 years

Category Fee:      x number of years:       = Total amount:      

PART G: Mode of Payment (Annual Subscription Fees)
[Please tick the appropriate option]

CHEQUE PAYMENTS - Please make your cheque payment made out to CIVICUS. Enclose this application form with your cheque and post to: CIVICUS, 1420 K Street NW, Suite 900, Washington, DC 20005, USA

WIRE TRANSFER PAYMENTS (Please supply us with proof of payment)

PNC Bank, NA; Philadelphia, PA (USA);
Branch Code: 256506;
Account Name: CIVICUS: World Alliance for Citizen Participation;
Account Number: 5305762375;
ABA Number: 031000053;
Swift Code: PNCCUS33.

Attention: 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.

CREDIT CARD PAYMENT

Please send this form with your credit card information by post or email to: CIVICUS, 1420 K Street NW, Suite 900, Washington, DC 20005, USA or [email protected]

Credit Card Type:

MasterCard VISA American Express

Name as it appears on the credit card:      

Card Number:      

Expiry Date:      

Membership Fee Payment Amount $:      

Donation Fee Payment Amount (Optional) $:      

Total Payment $:      

Signature of Card Holder:       ________________________________________________________

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.
(Please supply us with proof of payment)

Money Gram Western Union

Reference number:      

Receiver’s name: CIVICUS: World Alliance for Citizen Participation­­/Malauna Steele

Receiver’s Address: Silver Spring, Maryland, USA

Sender’s Name:      

Sender’s Residence:      

Sender’s Phone Number:      

Amount Sent:      

Test Question (If applicable):      

PART H: Declaration

On behalf of [Name of the organisation/Individual], I, undersigned, agree to abide by the Membership policy of CIVICUS: World Alliance for Citizen Participation and have read and understand CIVICUS’ vision, mission and values and agree to support them.

..........................................................................................................................................................

Signature

Date:   /  /    

Name:

Documents to be submitted by Institutional Organisations only:
Please submit at least 1 of these documents:

1. Copy of your organisation’s Registration as a Legal Entity/Document of Incorporation

2. Annual Report, financial accounts where it is a registered legal entity

3. Brochure, media clippings and/or manifesto where it is not a registered legal entity.
   
   

Please return your membership application form to CIVICUS:

1. By Post (USA): CIVICUS, 1420 K Street NW, Suite 900, Washington, DC 20005, USA.
   
   

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

Fax +27 11 833 7997 / Telephone: +27 11 833-5959

3. By e-mail: [email protected]
   
   

4. Online: http://www.civicus.org/join-civicus