2024 Membership Registration Form

2024 Membership Registration Form
EIN *
(9-digits, no dash)
Organization Legal Name*
Do you have a dba or other name you use?

YesNo
What is your DBA (Doing Business As) Name?
Are you renewing your membership or applying as a new member?*

Returning Member - same address, phone number and executive director name/emailReturning Member - we need to update our informationNew Member
New Members - please email these two required documents to Ev Coleman at ecoleman@onesourcectr.org

• Proof of tax-exempt status (IRS determination letter)

• Completed Ohio Sales and Use Tax Blanket Exemption Certificate
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Executive Director name and email*

NameEmail
Billing Contact name and email:*

NameEmail
Primary shopper for the Common Good Store (if you utilize this benefit)

NameEmail
Board Chair name and email:

NameEmail
EMAIL COMMUNICATIONS:

To subscribe any of your staff to receive our emails (monthly newsletter, training and professional development opportunties or product updates), sign up here:

https://onesourcecenter.org/newsletter-signup/.

To update preferences for any current subscriber, simply click on the update button at the bottom of any of our emails.
What is your annual budget? (As reported on line 12 of your most recent 990)*
Estimated number of individuals served annually
How many staff members do you have?*
Just a few more questions before we wrap up...
(Optional) Please let us know areas where we can assist you in 2024

Free 90-minute coffee chat with a consultantTour of the Common Good StoreUpcoming strategic planning or other consulting needsLeadership development programs for managerial or executive staffCustom staff training or individual coachingRegistration for taking any of the free Coursera online coursesHealth insurance plan for staffFree vouchers for agency clients to shop in Common Good StoreNo-cost agency financial checkupOther
What sector do you identify as your primary service area?*

Animal Care/EnvironmentArts/CultureChildren/Youth ServicesDisabled ServicesEducationEmployment/Workforce DevelopmentHealthHousingHuman Services (general)Immigrant and Refugee ServicesMental HealthRecovery/Alcohol/Drug TreatmentReligionSeniorsOther (specify)
What population do you primarily serve?*

BabiesChildren and YouthAdults onlyFamilies with ChildrenGeneral PopulationOther
Do your services include supporting your clients with products and/or furniture?*

Yes, oftenOccasionallyNoPossibly in the future
Do you provide residential services or group homes?*

YesNo
PAYMENT INFORMATION*

We will pay via credit card nowPlease invoice usHave already submitted payment
Review Benefits of Each Membership Level
Choose Your Membership Level

Basic Membership: Budget Under $500,000: Membership Fee $75Premium Membership: Budget Under $500,000: Membership Fee $150Basic Membership: Budget $500,000-$1M: Membership Fee $100Premium Membership: Budget $500,000-$1M: Membership Fee $200Basic Membership: Budget >$1M-$3M: Membership Fee $150Premium Membership: Budget >$1M-$3M: Membership Fee $300Basic Membership: Budget >$3M: Membership Fee $300Premium Membership: Budget >$3M: Membership Fee $600

Membership Levels

Basic Membership: Budget Under $500,000

$75.00 Quantity

Premium Membership: Budget Under $500,000

$150.00 Quantity

Basic Membership: Budget $500,000-$1M

$100.00 Quantity

Premium Membership: Budget $500,000-$1M

$200.00 Quantity

Basic Membership: Budget >$1M - $3M

$150.00 Quantity

Premium Membership: Budget >$1M - $3M

$300.00 Quantity

Basic Membership: Budget >$3M

$300.00 Quantity

Premium Membership: Budget >$3M

$600.00 Quantity

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Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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