Membership Invoice & Organization Profile
for July 1, 2017 to June 30, 2018
Please return these completed forms with your dues payment
Organization Name: ______________________________________________________
Mailing Address: ________________________________________________________
Telephone: ______________________________ Fax: _________________________
Website: _______________________________________________________________
Primary Representative: __________________________________________________
Position Title: ___________________________________________________________
Email: ________________________________________________________________
Members from your organization who may be attending InterAgency Coalition meetings
and their emails:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Annual dues: $30 per organization
Renewal ______
New member ______
Check #_______
Amount $________
Fiscal year: July 1, 2017 - June 30, 2018
Date: _________
Please make checks payable to: Martin County InterAgency Coalition
Mail these forms and your payment to:
Martin County InterAgency Coalition
PO Box 3012
Stuart, FL 34995-3012
ALSO e-mail these forms to: MCIAC President Renay Rouse,
[email protected]
MISSION STATEMENT
The purpose of the Martin County InterAgency Coalition is to provide a common meeting ground
to improve the service delivery system of health and human services in Martin County.
Martin County InterAgency Coalition
Member Profile 2017-2018
Organization
Name
Address
Telephone
Fax
Email
Web site
Contact(s)
Mission Statement
Constituents served
Description of agency/services
No. of employees
Economic Impact
Annual budget $
Local funding $
Please email both pages to [email protected]
and mail to: Martin County InterAgency Coalition
PO Box 3012
Stuart, FL 34995-3012
Outside funding $