Northwest Florida Clean Cities Coalition Membership Application Form
Name (last, first): ______________________________________ Date: ___________________
Organization: ___________________________________________ Local, Regional, National
Website: ________________________________ Fleet Vehicles: Yes / No. AFV: Yes / No
Address (Home or Business, indicate one): __________________________________________
City: State: Zip: _______________________________________________________________
Phone Home: ___________________ Phone Work: ___________________
Phone Mobile: ____________________ E-mail: ______________________________________
[ ] Check if you do NOT want your mailing address released to the public.
[ ] Check if you do NOT want your name included in marketing materials.
1) Desires and/or expectations for participating in the Northwest Florida Coalition for the Clean Cities
Program.
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______________________________________________________________________________
2) Alternative Fuel Vehicle, environmental, health, etc. relevant experiences you bring to the coalition.
______________________________________________________________________________
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Send form To: Northwest Florida Clean Cities Coalition
4081 E. Olive Rd. Ste A
Pensacola, FL 32514
Email: [email protected]
Please indicate your category/level of membership. Expect the appropriate calendar annual dues
invoiced if your membership application is approved by the Board of Directors.
___$ 25 Goal Setter (individuals only)
___$ 250 Bronze Partner
___$ 500 Silver Partner
$ 1,000 Gold Partner
___2 equal payment in 6 months timeframe or ____ payment in full
$2,000 Emerald Partner Board of Director Eligibility
___ 4 equal payments in 6 months timeframe or ____ payment in full
___ Community/Education/Government Non-Profit Partner: This partner joins the coalition in
support of its efforts and meeting coalition goals. There is no fee for this category.
Northwest Florida Clean Cities Coalition
Emerald Partner
An Emerald partner is a three year, $2,000 per year executive partnership participating as an elected Board
Member with the coalition. The partner completes the coalition’s letter of intent to run for a board position.
The letter indicates the organization’s three year commitment to the coalition’s financial stability, goals and
mission. The candidate must select to represent one of the ten director seats. Winning the seat is by majority
vote determined by the voting membership. Anyone is welcome to run and if elected must make a sincere effort
to commit to the Emerald partnership agreement.
Rules:
The coalition’s letter of intent must be completed and submitted to the coalition requesting election status
with intent to commit to the Emerald partnership agreement.
Only two companies with similar interests can partner together to become an Emerald Partner splitting the
per year partnership fees with payment options.
The designated primary organization will be responsible for the financial agreement.
The primary organization must designate a primary representative running for the director position and
indicate with who their alternate representative is. The alternative representative can be a member from the
partner organization.
Only one vote can be cast. If the partnership organizations are at odds on an issue it is their responsibility to
resolve it. The coalition will accept only the vote cast at a board meeting by the authorized representative who
casts the vote. If one partner dissolves the relationship the primary organization is responsible for the financial
obligation.
All Emerald Partners will be allowed to designate only one alternative representative to proxy a vote for them
at board meetings. On the letter of intent the alternative representative must be identified. Due to unforeseen
circumstances an alternative representative can be changed with a formal request to the board.
Benefits:
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Executive partnership recognition in marketing materials, web site and events.
Organization/individual has privileges to promote Emerald membership in their marketing
materials
Six annual dinner tickets
Each year $200 will be applied to support coalition goals in the community by awarding
grants or scholarships to applicants.
Coalition Board member with one voting privilege pertaining to the management, goals and
mission of the Coalition.
Ten Emerald Coast Coalition UV/Weather Resistant Exterior Decals, with appropriate
level recognition, for display on store fronts, automobile windows, etc…
Gold Partner
A Gold Partner enrolls in an individual one year membership. The fee is $1,000.
Benefits:
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Recognition in marketing materials, web site and events
Organization/individual has privileges to promote Gold membership in their marketing
materials
For the year $100 will be applied to support coalition goals in the community by awarding grants
or scholarships to applicants.
Coalition Committee participation
One general membership vote for election of Emerald Partner Board Members
Five Emerald Coast Coalition UV/Weather Resistant Exterior Decals, with appropriate level
recognition, for display on store fronts, automobile windows, etc…
Silver Partner
A Silver Partner enrolls in an individual one year membership. The fee is $500.
Benefits:
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Recognition in marketing materials, web site and events
Organization/individual has privileges to promote Silver membership in their marketing
materials
For the year $50 will be applied to support coalition goals in the community by awarding grants
or scholarships to applicants.
One general membership vote for election of Emerald Partner Board Members
Two Emerald Coast Coalition UV/Weather Resistant Exterior Decals, with appropriate level
recognition, for display on store fronts, automobile windows, etc…
Bronze Partner
A Bronze Partner enrolls in an individual one year membership. The fee is $250.
Benefits:
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Recognition in marketing materials, web site and events
Organization/individual has privileges to promote Bronze membership in their marketing
materials
One general membership vote for election of Emerald Partner Board Members
Two Northwest Florida Coalition UV/Weather Resistant Exterior Decals, with appropriate level
recognition, for display on store fronts, automobile windows, etc…
For the year $25 will be applied to support coalition goals in the community by awarding grants
or scholarships to applicants.
Government Entity
This partner joins the coalition at no cost to the partner through the means of a Resolution in support of the
Florida Emerald Coast Clean Cities Mission to reduce America’s dependence on imported oil, improve the
environment by creating a sustainable alternative fuel market through the support and promotion of clean
fuels and to promote sustainable economic development opportunities for the region.
Benefits:
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Membership recognition
Recognition on the website and in specific materials
Participation in committees
Can purchase Northwest Florida Coalition (Proud Partner) UV/Weather Resistant Exterior
Decals at$5.00 each, for display on store fronts, automobile windows, etc…
Clean Cities Goal Setter
A clean cities goal setter enrolls in a one year membership of $25. A goal setter is any individual (no
companies) whom wish to participate in achieving the coalition’s goals by supporting coalition partners in their
endeavors to replace 20% of transportation petroleum use with alternative fuels by 2020 as well as reduce 20%
transportation harmful emissions by 2020. Examples are, but not limited to: Consolidate two trips to the store
into one trip per week. My new car purchase will get an estimated 25 miles to the gallon city driving. My new
car purchase allows for me to use alternative fuels.
Benefits:
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Membership recognition
Recognition on the web site and in specific marketing materials
One Emerald Coast Coalition (Proud Partner) UV/Weather Resistant Exterior Decal, for display on
automobile window, etc…
Community/Education/Non-Profit Partner
This partner joins the coalition in support of its efforts and meeting coalition goals. Support is provided as in-kind.
This may include but is not limited to attendance at meetings, volunteering for projects/programs, and support
through marketing materials.
Benefits:




Membership recognition
Recognition on the web site and in specific materials
Participation in committees
Can purchase Northwest Florida Coalition (Proud Partner) UV/Weather Resistant Exterior
Decals at$5.00 each, for display on store fronts, automobile windows, etc...
Please contact Clean Cities Coordinator at 850-332-7976 ext. 203 or [email protected]
for questions or additional information.