Member Join and Payment Form Member Information Organization: Address: City/State/Zip: Telephone: Website: Designated Representative: Each CAEAR member has a designated representative who is the primary contact for CAEAR Coalition matters. This individual has the right to cast votes on behalf of the member organization and run for an at-­large seat on the Board of Directors. Name: E-­mail: Additional Representatives: Please list other contacts within your organization that should receive CAEAR Coalition action alerts, information updates, and meeting announcements. These individuals have the right to be nominated by CAEAR Coalition caucuses to the Board of Directors with agency approval. Name: E-­mail: Name: E-­mail: Name: E-­mail: Membership Category Check the membership category that applies to your organization. See the attached CAEAR Coalition Member Dues Chart for corresponding dues amount. □ Part A Grantee with a Ryan White Award <$5M □ Part A Grantee with a Ryan White Award $5M-­$10M □ Part A Grantee with a Ryan White Award >$10M □ Part A Planning Council □ Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award<$750K/ Overall Agency Budget <$10M □ Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award <$750K/Overall Agency Budget >$10M □ Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award $750K-­$2M □ Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award >$2M □ Corporate and Industry Affiliate Members □ Non-­Aligned Consumer Payment Options Credit Card: □ Amex □ MC □ Visa □ Check Card #:________________________________________________ Make check payable to CAEAR Coalition Exp. Date: _________________ Security Code:_______________ and mail it, along with this completed Name on Card: _________________________________________ form, to Billing Address: ________________________________________ City/State/Zip: _________________________________________ CAEAR Coalition Phone: _______________________________________________ P.O. Box 21361 Amount:_______________________________________________ Washington, DC 20009 Need an Invoice? Questions? E-­mail [email protected] or call 202-­789-­3565. Member Dues Chart Membership Category Part A Grantees Part A Grantee with a Ryan White Award <$5M Part A Grantee with a Ryan White Award $5M-­$10M Part A Grantee with a Ryan White Award >$10M Part A Planning Councils Part A Planning Councils Part A & B Sub-­Grantee/Part C Grantee (Ryan White Award <$750K) Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award<$750K and an overall Agency Budget <$10M Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award <$750K and an overall Agency Budget >$10M Part A & B Sub-­Grantee/Part C Grantee (Ryan White Award >$750K) Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award $750K-­$2M Part A & B Sub-­Grantee/Part C Grantee with a Ryan White Award >$2M Corporate and Industry Affiliate Members Corporate and Industry Affiliate Members Non-­Aligned Consumers Non-­Aligned Consumers CAEAR Coalition Annual Membership Dues $3,000 $6,500 $8,500 $500 $3,000 $6,500 $6,500 $8,500 $15,000 $100 CAEAR Coalition · P.O. Box 21361 · Washington, DC, 20009 · Tel: 202-­789-­3565 · www.CAEAR.org