Membership Application

For Printable Version of this form Click Here

2003 HELP Membership Invoice

Name of Organization:

Organization, Institution, Corporation, Business, Individual, or other entity

Street Address:

City: Zip: Telephone: Fax:

County: E-Mail Address:

Web Site Address: Preferred way to be contacted:

Has your organization been a member of Help before? Yes No

Name of Primary Contact:

Name (if differs from above) Title Telephone

**Please attach a brief description of your organization, institution, business or corporation, including information on community-based development activities.

Annual Agency Membership Contributions (check appropriate category):

Membership Fee	Operating Budget:
$50	$50,000 or less
$100	$50,001 - $100,000
$150	100,001 - $250,000
$200	$250,001 - $500,000
$300	$500,001 - $1 million
$400	$1 million - $1.5 million
$500	More than 1.5 Million

*For Government Agencies, determine income level on lead prevention program only

Annual Individual Membership Contributions (check appropriate category):

$10	Low Income
$35	Regular
$75	Benefactor
$250	Sustainer
	Fee Waiver Requested

Friends of HELP

I would like to contribute an additional amount to support Help End Lead Poisoning's mission to eliminate childhood lead poisoning in Ohio

$25 $50

$75 $100

$ Other

Signature (person completing application)

If submitting online, please print name here Date

To join Help End Lead Poisoning electronically, Click "Submit" and mail payment to the address below.

If you prefer, you may PRINT and FAX this page to (614)461-1011 and MAIL payment (or payment and application) to:

Help End Lead Poisoning

35 East Gay Street, Suite 400

Columbus, Ohio 43215

If you have any questions, please contact Marian Harris at (614) 461-6392.

HELP Homepage