CIVICUS
Membership Application Form
CIVICUS is an international alliance dedicated to strengthening citizen action and civil society throughout
the world. Our vision is of a worldwide community of informed, inspired, committed citizens engaged in
confronting the challenges facing humanity.
CIVICUS is independent of any government, political persuasion or religious creed, being concerned
solely with the protection and freedom of all people to exercise their rights as citizens, to organise and
act collectively towards defined goals for the public good as defined in the Universal Declaration of
Human Rights.
I / We would like:
to apply for CIVICUS membership
to renew my CIVICUS membership
Please complete the details below. [Please tick the appropriate option(s)]
PART A: Applicant Details
Organisation Name:
Mailing Address:
City:
Postal Code:
Country:
Telephone No:
Fax:
Email:
Website:
Organisation description:
(300 words max in
English or 150 in English
and
150
in
your
country’s language)
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CIVICUS
Membership Application Form
Type of Organisation/
Profession:
Cultural group/organisation
Development practioners
Faith-based organisation
Grass-roots organisation
International non-governmental organisation
Media agency
Network and/or alliance (national, regional or international)
Non-Governmental organisation
Philanthropic / Funding organisation
Research institute / Think tank
Sports Association
Trade or professional association (inc trade unions)
University / Educational establishment
Volunteer sending organisation
Individual Member
Publish?
Can your details be
made public in CIVICUS
Membership Directory?
Yes, we would appreciate our organisation’s details published in the Membership
Directory.
No, our organisation’s details should remain confidential and NOT published in the
Membership Directory.
PART B : Key Contact People for CIVICUS (Only for Institutional Membership)
Name(s)
Job Title(s):
E-mail:
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CIVICUS
Membership Application Form
PART C: Referral
Heard About CIVICUS?
Name/Who/Where
Current CIVICUS
Member
CIVICUS Staff Member
CIVICUS Website
e-CIVICUS
Social Network
Direct Mailing
Media
Event/Conference
referred?
Organisation:
Date:
PART D: Activity Areas
Accountability
Housing
Agriculture/Farming/Fishing/Forestry
Human rights and social justice
Animal Welfare/Rights
Humanitarian relief
Arts and Culture
Indigenous peoples (inc land rights)
Children/Youth
Information Communication Technology
Civic Participation and Volunteerism
International institutions (UN, IFIs etc)
Civil Society Strengthening
Law and legal reform
Climate Change
Media/journalism/press freedom (inc alt &
community media)
Men/boys
Conflict Resolution/Peace/Security
Disability
Microfinance
Economics/Trade
Poverty/MDGs
Education (inc ECCD) and skills development
Religion
Energy/Extractive industries
Seniors
Environment/Conservation
Slavery/human trafficking
Ethnicity/Race
Sport
Food/Nutrition
Sustainable Development
Forced Migration/Refugees
Technology
Gender and Sexuality
Volunteerism
Globalisation
Water/Sanitation
Governance and Transparency (inc local governance)
Women/girls
Health (inc addiction, excl HIV/AIDS)
Workers rights (inc sex workers)
HIV/AIDS
Geographical
Focus
Single country
Specify:
Multi country Africa region
Specify:
Multi country Americas Region
Specify:
Multi country Asia Region
Specify:
Multi-country Europe Region
Specify:
Multi Country Oceania Region
Global (multiple countries in multiple
regions)
Preferred Language of
Communication
French
English
Spanish
Other
Specify:
Specify:
Portuguese
Please specify:
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CIVICUS
Membership Application Form
PART E: Interest in CIVICUS
How
would
the
organisation/you would
like to participate in
CIVICUS activities
[Please
tick
the
appropriate option(s)]
Undertake activities to accomplish CIVICUS Mission, Vision and Values
Participate in CIVICUS events
Participate in The Civil Society Index (CSI) Programme
Participate in The Civil Society Watch (CSW) Programme
Participatory Governance (PG) Programme
Apply to be a CIVICUS Membership Country/Regional Representative – on a
Volunteer basis
Apply to a be part of the CIVICUS Affinity Group of National Associations
Adopt the International Non-Governmental Organisations Accountability Charter
(IANGO)
Contribute with sponsorship to various CIVICUS activities and events
.....................................................................................................
[others]
.....................................................................................................
[others]
.................................................................................................
[others]
PART F: CIVICUS MEMBERSHIP CATEGORIES
Please select the category you wish to apply for. For further information on categories, please see the CIVICUS
Membership policy available from the membership section of our website at www.civicus.org
Citizen Organisation
Annual Income in US$
Group
Group
Group
Group
Group
Group
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2
3
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Fee
up to $75,000
$75,001 to $250,000
$250,001 to $500,000
$500,001 to $1,000,000
$1,000,001 to $3,000,000
$3,000,001 and over
$50
$75
$125
$200
$300
$500
Grant-making Organisation
Fee required is 0.1% of the organisation's annual grants
(Min. amount $500 and max. amount $10,000).
Individual Member
Youth Member (Individual Membership for ages 16-24)
From a developing country $50
From a developed country $100
From a developing country $15
From a developed country $25
Please indicate your age:
I would like to pay for:
Category Fee:
1 year
x number of years:
2 years
3 years
= Total amount:
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CIVICUS
Membership Application Form
PART G: Mode of Payment (Annual Subscription Fees)
[Please tick the appropriate option]
CHEQUE PAYMENTS - Please make your cheque payment made out to CIVICUS. Enclose this application
form with your cheque and post to: CIVICUS, 1425 K Street NW, Suite 350, Washington, DC 20005, USA
WIRE TRANSFER PAYMENTS (Please supply us with proof of payment)
PNC Bank, NA; Philadelphia, PA (USA);
Branch Code: 256506;
Account Name: CIVICUS: World Alliance for Citizen Participation;
Account Number: 5305762375;
ABA Number: 031000053;
Swift Code: PNCCUS33.
Attention: Please ensure that you reference your name or organisation name in the transaction, and
that you make a total payment of the Membership Fee, plus any banking fees / charges.
CREDIT CARD PAYMENT
Please send this form with your credit card information by post or email to: CIVICUS, 1425 K Street NW, Suite
350, Washington, DC 20005, USA or membership@civicus.org
Credit Card Type:
MasterCard
VISA
American Express
Name as it appears on the credit card:
Card Number:
Expiry Date:
Membership Fee Payment Amount $:
Donation Fee Payment Amount (Optional) $:
Total Payment $:
Signature of Card Holder:
________________________________________________________
MONEY GRAM & WESTERN UNION OPTIONS (money sent to U.S. only)
Please ensure that you reference your name or organisation name in the transaction, and that you make a total
payment of the Membership Fee, plus any banking fees / charges.
(Please supply us with proof of payment)
Money Gram
Western Union
Reference number:
Receiver’s name: CIVICUS: World Alliance for Citizen Participation/Rachel Zutshi
Receiver’s Address: Maryland, USA
Sender’s Name:
Sender’s Residence:
Sender’s Phone Number:
Amount Sent:
Test Question (If applicable):
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CIVICUS
Membership Application Form
PART H: Declaration
On behalf of [ N a m e o f t h e o r g a n i s a t i o n / I n d i v i d u a l ] , I, undersigned, agree to abide by the Membership policy of
CIVICUS: World Alliance for Citizen Participation and have read and understand CIVICUS’ vision, mission and
values and agree to support them.
..........................................................................................................................................................
Signature
Date:
/
/
Name:
Documents to be submitted by Institutional Organisations only:
Please submit at least 1 of these documents:
1.
Copy of your organisation’s Registration as a Legal Entity/Document of Incorporation
2.
Annual Report, financial accounts where it is a registered legal entity
3.
Brochure, media clippings and/or manifesto where it is not a registered legal entity.
Please return your membership application form to CIVICUS:
1.
By Post (USA): CIVICUS, 1425 K Street NW, Suite 350, Washington, DC 20005, USA.
2.
By Post or Fax (RSA):
3.
By e-mail: membership@civicus.org
4.
Online: http://www.civicus.org/join-civicus
CIVICUS, PO Box 933, Southdale, Johannesburg, 2135, South Africa
Fax +27 11 833 7997 / Telephone: +27 11 833-5959
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