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MACH Membership Application
Contact Information
Member Name (If Organizational Member)
*
Individual members enter N/A.
Member Name (If Individual Member) or Primary Representative (If Organizational Member)
*
Prefix
First Name
Last Name
Suffix
Alternate Representative (For Organizations)
Prefix
First Name
Last Name
Suffix
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Primary Phone Number
*
Secondary Phone Number
Email
*
Verify Email
*
If you provide assistance for homeless persons, please describe the type(s) of services you offer:
What is your interest in problems related to homelessness?
For Organizational Members: Check below
Unincorporated Organization
Corporation
Government Entity
Other
N/A
Tax Determination
Profit
Non profit
N/A
If Non-Profit, what type:
IRS 501c(3) charitable
Public/Governmental
Faith-Based
Other
N/A
If Non-Profit, what type: Copy
IRS 501c(3) charitable
Public/Governmental
Faith-Based
Other
N/A
Membership Dues
*
$50
-
Organizational Member
$10
-
Individual Member
Dues Schedule
One Time
Monthly
Quarterly
Yearly
I wish to make a donation
$10 - Purchases a hygiene kit for a person living on the street or under a bridge
$25 - Purchases a State ID for a homeless person to use to access services
$50 - Purchases a one-month bus pass for a homeless person to seek employment
$100 - Supports daily activities of the Street Outreach Worker
$500 - Supports our work to coordinate services among area agencies
$ Other Amount
Add 3% to my total amount to help cover the payment processing fees