An Alliance of Missouri's Nonprofit Organizations

Membership Application

Member/Organization Name: _________________________________________________

Organization Phone:__________________ Organization Website:___________________
Executive Director/CEO:
Prefix: _____ First Name: ____________________ Last Name: ______________________
Title: ________________________ Email: ________________________________________
Phone: ___________________________________ Fax: ____________________________
Primary Contact Person (if other than ED/CEO):
Prefix: _____ First Name: ____________________ Last Name: ______________________
Title: ________________________ Email: _______________________________________
Phone: ___________________________________ Fax: ____________________________
Mailing Address: __________________________________________________________
Address 2: ________________________________________________________________
City: _____________________ County: _________________State: ______Zip: _________
Street Address (if different): __________________________________________________
Address 2: ________________________________________________________________
City: _____________________ County: _________________State: ______Zip: _________
Organization Status: □ Tax Exempt 501(c)3 □ Other: _____________________________
Number of Employees: Part time __________ Full time __________ Seasonal __________
US Congressional District: _____ (see http://www.house.gov/)
Missouri House District: _____ (see http://www.sos.mo.gov/elections/maps/house/)
Missouri Senatorial District: _____ (see http://www.sos.mo.gov/elections/maps/senate/ )
How did you hear about Nonprofit Missouri?_______________________________________
__________________________________________________________________________

Area of emphasis that most closely defines the work of your organization:
□ Arts & Humanities □ Law
□ Environment & Animals □ Human Services
□ Economic & Community Development □ Government
□ Education □ Volunteerism
□ Health □ Youth & families
□ Finance □ Faith Based
□ Foundation □ Other __________________________
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www.nonprofitmissouri.org
 An Alliance of Missouri's Nonprofit Organizations

Membership dues are based on the organization/foundation’s annual operating budget.

Membership Category By Annual Mem- Discounted

Annual Operating Budget bership Fee fee*
up to $250,000 $125 $100
$250,000-500,000 $250 $200
$500,000-1 Million $375 $300
$1-5 Million $500 $400
$5 Million + $1,000 $800
Other Categories:
Students $20 $16
Individuals $75 $60
Government and Others $250 $200
Businesses/Consultants:
Small (<50 employees) $375 $300
Large (>50 employees) $1,000 $800

* Members enrolling prior to June 30, 2011 (the end of first full fiscal year) will be considered “Inaugural
Members” and receive a 20% reduction in published membership fees for their initial year of membership.

Annual Dues based on above: $___________________________

Leveraged Resources Management (ARCHS) is currently acting as fiscal agent for Nonprofit
Missouri. You may pay by Visa, MasterCard or check.

Name as it appears on credit card____________________________________________

□ Visa □ MasterCard Card #_____________________________________________

Expiration Date_____________ Security Code_____

Make checks out to ARCHS with “Nonprofit Missouri” noted in the Memo section and
mail with this completed application to:
ATTN: Terry Blake, President
Leveraged Resources Management (LRM)
c/o ARCHS
539 N Grand Blvd, 5th Floor
St. Louis MO, 63103

The Mission of Nonprofit Missouri is to improve the lives of all people and communities in Missouri
by promoting, protecting, supporting, connecting, and serving Missouri’s nonprofit sector.

www.nonprofitmissouri.org