National Council on Independent Living 2018 Member Application Form - Memberships will be accepted throughout the year, but CIL & SILC dues must be paid in full 30 days prior to the commencement of NCIL's Annual Conference to ensure voting privileges at the Annual Council Meeting. - Upon payment of appropriate dues, it shall be assumed that a member unreservedly and sincerely supports NCIL's mission, vision, and guiding principles; copies of which shall be sent to all members annually. Membership Type You may use this form to join as an organization and an individual if the contact information is the same. [ ] Individual: $35 [ ] Youth (26 and under): $10 [ ] CIL [ ] SILC [ ] Other Organization Please select: [ ] New Member [ ] Renewing Member Contact Information Prefix: Name: Organization (if applicable): Title (if applicable): I prefer to receive NCIL information at my: [ ] Home [ ] Business [ ] The rest of my contact information remains the same as 2017 (skip to payment information) Email: Address: Apt / Suite #: City: State: Zip Code: Region (if known): Phone: Fax: TTY: Website: - For CILs, SILCs, & Organizations: Your Net Annual Operating Budget (minus pass-through funds): - CIL / SILC / Organizational Dues: - Individual Dues: - Additional Donation: Please charge my: [ ] Visa [ ] MasterCard [ ] American Express [ ] Discover [ ] I'm sending a check Total amount: Name on Card: Expiration: CID / CIV: Card #: Organizational Dues Chart NCIL Organizational Dues Chart: For Centers for Independent Living, Statewide Independent Living Councils, and other organizations Operating Budget (minus pass-through funds) = Dues - Less than $100,000 = $150 - $100,000 - $200,000 = $300 - $200,000 - $300,000 = $450 - $300,000 - $400,000 = $600 - $400,000 - $500,000 = $750 - $500,000 - $600,000 = $900 - $600,000 - $700,000 = $1,050 - $700,000 - $800,000 = $1,200 - $800,000 - $900,000 = $1,350 - $900,000 - $1 Million = $1,650 - $1 Million - $3 Million = $1,950 - $3 Million - $5 Million = $2,250 - $5 Million - $8 Million = $2,625 - $8 Million - $11 Million = $3,675 - $11Million - $15 Million = $5,250 - More than $15 Million = $7,875