Michigan Coalition to End Domestic and Sexual Violence · Organization Supporting Member Registration

Please select your dues amount based on your organization's annual budget *

$825 - ($1 million or greater)

$725 - ($750k - $999k)

$600 - ($501k - $749k)

$500 - ($100k - $500k)

$210 - ($99k or less)

Full name of your organization *

Name of individual completing this form *

First Name

Last Name

Name of your organization's president/director/CEO *

First Name

Last Name

You preferred phone number *

Your preferred email address *

Verify Email *

What sort of services to you provide? (Check all that apply)

Domestic Violence

Sexual Assault

Transitional Housing

Human Trafficking

Dating Violence

Stalking

Do you serve a rural or urban community? *

Rural

Urban

Both rural and urban

If you identify your organization as a Culturally Specific Program, please select your primary population served.

American Indian

Asian American

Black

Hispanic

LGBTQUI+

Disabled

Other

If you chose "Other" in the previous question, please enter your organization's primary population served.

Contact Information

Mailing address of your organization *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Invoice Option

Please check here if you need to pay with a check. You may then submit this form below and simply ignore the payment screen on the next page. We will mail an invoice to your organization's mailing address.