WIEC Membership Application Form
Organization:
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Membership Levels
Standard:
75 % Board & Staff Indigenous, led by Indigenous Executive Director; functions according to Indigenous cultural values and principles.
Associate:
Indigenous Executive Director; non-Indigenous Organization
Indigenous Organization; Led by non-Indigenous Executive Director
Date of Coverage 2022
Levels
Annual Budget
Standard
Associate
Level 1
< $1,000,000
$200
$400
Level 2
$1,000,000-5,000,000
$300
$600
Level 3
>$5,000,000
$500
$1000
Choose Membership Level
Standard
Associate
Standard:
*
Level 1: $200
Level 2: $300
Level 3: $500
:
*
Level 1: $400
Level 2: $600
Level 3: $1000
Signature:
*
Date
*
-
Month
-
Day
Year
Date
Submit Registration
Submit Registration
Should be Empty: