2016 Philanthropy Ohio Membership Form
New Member
Renewal
Please choose one:
Check Enclosed
Invoice Us
Organization
or Individual
Donor
Address
City
State
Phone
Zip Code
Website
Facebook
Twitter
LinkedIn
Primary Contact/
Individual
Blog
Title
Contact’s Phone
number
Email
Membership Type and Giving
Membership Support Calculation
(Please select one)
(For Foundations, Federated Funds, Corporate Giving Programs)
Individual Donor
Philanthropic Giving Circle
Government Grantmaking Agency
Community Foundation
Corporate Foundation
Corporate Giving Program
Private Foundation
Federated Fund
United Way
Operating Foundation
Grantmaking Public Charity
Does your organization have paid staff?
Number of full-time staff:
Number of part-time staff:
Yes
No
Types of Giving
$
2013 Grants/Giving
$
2014 Grants/Giving
$
2015 Grants/Giving
$
Total Grants/Giving
$
Total Grants/Giving Divided by 3
$
Multiplied by 0.0022
$
2016 Total Support
$
Minimum Support: $525, Maximum Support: $12,500; Support above
$525 may be made as a grant rather than taken as an administrative
expense.
Membership Support
(Check as many as apply)
Advocacy
Capacity-building
Capital Campaigns
Emergency Funds
Total Assets
(For Individual Donors, Giving Circles and Government Grantmaking Agencies)
General Operating
Loan/PRI’s
Program/Project Specific
Other:
Individual Donors and Giving Circles*
$525
Government Grantmaking Agencies*
$1,000
2016 Total Support
$
*Please contact Philanthropy Ohio at 614.224.1344 with any questions.
Return form to: Philanthropy Ohio | 500 South Front Street | Suite 900 |Columbus, Ohio 43215-7628
614.224.1344 | philanthropyohio.org
Other Memberships
I/We belong to the following philanthropic organizations:
Council on Foundations
Association of Small Foundations
OANO
Ohio United Way
United Way Worldwide
National Affinity Group:
Other:
Independent Sector
GMN
GEO
Please indicate your primary giving interests
(Check as many as apply)
Affordable Housing
Aging
Arts & Culture
Children, Youth and Families
Communications/Media
Disaster Relief
Diversity
Early Childhood
Education
Environment/Animals
Health
Healthy Food
HIV/AIDS
Homelessness
Human Services
International/Foreign Affairs
Juvenile Justice
LGBTQ
Poverty
Public Policy
Religion
Science & Technology
Smart Growth
Social Justice
Social Science & Economics
Sustainability
Veterans
Women
Workforce
Other:
Guiding Principles, Diversity and Contact Consent
I/We intend to abide by the applicable Guiding Principles and be informed by the Diversity Principles. I am authorized to and hereby consent for
this organization or individual to receive correspondence sent by or on behalf of Philanthropy Ohio.
X
Name and Title
If digitally signing this document, double click the Sign dialog box and select “ok.” Then click “select image” and locate your signature image file
and click Select. You can also print this document out and include your handwritten signature.
Additional Organizational Contacts
Please list the names you wish to be entered into Philanthropy Ohio’s database. The individuals listed will only be contacted when
appropriate. Please include addresses if different from organization’s address. Include additional pages, if necessary.
Contact
Title
Phone
Email
Address
Contact
Title
Phone
Email
Address
Contact
Title
Phone
Email
Address
Contact
Title
Phone
Email
Address
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