Join Arizona Disability Advocacy Coalition (AZDAC)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
If applying for an Organizational Membership, please also provide:
Organization Name
Organization Mission
Organization Website
Alternate Contact
First Name
Last Name
Alternate Email
example@example.com
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Membership Levels:
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( X )
Individual Membership
$
20.00
Organization Membership | Budget Under $100K
$
50.00
Organization Membership | Budget $100K - $249K
$
100.00
Organization Membership | Budget $250K - $499K
$
200.00
Organization Membership | Budget $500K - $999K
$
350.00
Organization Membership | Budget $1M -$1.5M
$
750.00
In-Kind Resource Contribution
$
Free
Offline Resource Contribution
(AZDAC will reach out to you)
$
Free
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
In-Kind Resource Description (if applicable)
I certify that I/my organization supports AZDAC’s mission, vision, and values and will follow all membership guidelines. I further attest that I/my organization will make the required annual resource contribution.
*
Yes
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