Its 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.
I / We would like:  to apply for CIVICUS membership (for membership categories and fees, please see below)
 to renew my CIVICUS membership (for membership categories and fees, please see below)
 to support CIVICUS’ work with a donation of
(please indicate $ or €)
Please complete the below chart, and mark with an “X” any items that we should not post on CIVICUS’ website:
ITEM
Name:
Position:
Organisation Name:
Postal address:
City:
Country:
Telephone:
Fax:
Email(s):
Website:
MARK WITH “X”
DETAILS
 I / We have read and understand CIVICUS’ vision, mission and values and agree to support them.
SIGNED:
DATE:
CIVICUS MEMBERSHIP CATEGORIES
Please tick below the category for which you wish to apply. For further information on categories, please see the
CIVICUS Membership policy available from the membership section of our website at www.civicus.org. Please
contact us (see pg 2) if you cannot pay in US Dollars or Euros.
Citizen Organisation
Annual Income in US$ or Euros €
Fee
(Estimated Conversion Rate: USD = 0.823460 EUR)






Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
up to $75,000 / € 60,000
$75,001 to $250,000 / €60,001 to €200,000
$250,001 to $500,000 / €200,001 to €400,000
$500,001 to $1,000,000 / €400,001 to €800,000
$1,000,001 to $3,000,000 / €800,001 to €2,500,000
$3,000,001 and over / €2,500,001 and over
$50 / €40
$75 / €60
$125 / €105
$200 / €165
$300 / €250
$500 / €410
Grant-making Organisation
 Fee required is 0.1% of the organisation's annual grants
 (Minimum Amount $500 / €410 and Maximum Amount $10,000 / €8,235).
 Corporate Member $500 / €410
Individual Member
 From a developing country $50 / €40
 From a developed country $100 / €80
Youth Member (Individual Membership for ages 16-24)
 From a developing country $15 / €10
 From a developed country $25 / €20
I would like to pay for:
 1 year
 2 years
 3 years
Category Fee
x number of years
=Total amount
On-line Membership Registration: If you would like to apply for or renew your CIVICUS Membership on-line, visit
http://www.civicus.org/new/joinv2.html
ORGANISATION DESCRIPTION:
_________
___
What areas/fields is your organisation mainly involved in? Please mark with an “X” all fields that apply.
Civil Society Strengthening/Support
Democracy and Governance
Human Rights & Legal issues
International Development
Health
Environment
Culture & Recreation
Education & Research
Economic Development
Housing & Homelessness
Professional Association/Union
Community development
Social Care & Services
Religious Activities
General Charitable Purposes
Other:
METHOD OF PAYMENT: Please tick your preferred method.
CHEQUE PAYMENTS
* Please make your cheque payment made out to CIVICUS and enclose your cheque with the completed
membership application form and send by post to:
 U.S. Dollars:
CIVICUS, 1420 K Street NW, Suite 900.Washington, DC 20005, USA.
 Euros:
CIVICUS, PO Box 933, Southdale, Johannesburg, 2135, South Africa.
WIRE TRANSFER PAYMENTS
* 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.
 Wire Transfer in U.S. Dollars:
PNC Bank, NA; Philadelphia, Pennsylvania (USA); Branch Code: 256506; Account Name: CIVICUS: World
Alliance for Citizen Participation; Account number: 5300750957; ABA number: 031000053; Swift Code:
PNCCUS33.
 Wire Transfer in Euros:
First National Bank Ltd, Melville, South Africa; Branch Name: Melville Outlet; Branch Code: 256505; Account Name:
CIVICUS: World Alliance for Citizen Participation – Membership Account; Account number: 62083227788; SWIFT
Code: FIRNZAJJ950.
Wire transfer payment made on _ _/_ _/ _ _ _ _ (Month/Day/Year)
CREDIT CARD PAYMENT
* Please send this form with your credit card information by post, fax, or email to: Address CIVICUS, 1420 K
Street NW, Suite 900.Washington, DC 20005, USA / Fax+1 202 331 8774
Email: membership@civicus.org. (please include your authorisation in writing to charge your credit card).
 Credit Card:
Name as it appears on the credit card
Card type:
 MasterCard
 VISA
 American Express
Card Number
Expiry date
Currency and amount
Signature of Card Holder
Amount to be paid: Membership fee $/€
Total payment $/€
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.
 Money Gram
 Western Union
Reference number:
Receiver’s name: Patricia Benton/CIVICUS: World Alliance for Citizen Participation
Receiver’s Address: 1420 K Street NW, Suite 900.Washington, DC 20005. Tel: 202-331-8518
Sender’s name:
Sender’s Residence:
Sender’s Phone Number:
Amount Sent:
Test Question (If applicable):
To help us estimate the effectiveness of our communications efforts, please provide a description of your
organisation and indicate how you first learned about CIVICUS:
 e-CIVICUS bulletin
 Referral from a CIVICUS Member
 Meeting with a member of CIVICUS staff (please include Programme or Department name
)
 CIVICUS website
 Other (please state
)
Please return this completed form to CIVICUS:
a) By Post or Fax (USA):
CIVICUS, 1112 1420 K Street NW, Suite 900.Washington, DC 20005. USA
Fax: +1 202 331 8774 / Telephone: +1 202 331 8518
b) By Post or Fax (RSA):
CIVICUS, PO Box 933, Southdale, Johannesburg, 2135, South Africa
Fax +27 11 833 7997 / Telephone: +27 11 833 7997
c) By e-mail:
membership@civicus.org
2
When returning this form, please assist us in keeping up-to-date records about your organisation’s work by sending us a copy of your annual report,
or any other programmatic information available by post or fax (RSA Office), or by email.