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Join NPower Indiana
 
NPower Indiana > Join NPower Indiana


NPower Indiana Membership Application Form

The membership form has a 35 minute time out. Please make sure you have all the required information available before starting to fill out the form.

* indicates required fields
  1. Basic Information
    2. * Agency Name:
    * Address : (address 1)
    (address 2)
    (city) , (zipcode)
    * Phone : (i.e. 123-123-1234)
      Fax : (i.e. 123-123-1234)
      Email : (general email address)
      Website : Http://
    * Employeer ID Number :
    [From IRS 501(C)(3) letter]
      How many people work at the above location
    (Note: This location only, not other locations where you have offices or affiliates.)
     
      What are your hours of operation at the above location
    (Note: This location only, not other locations where you have offices or affiliates.)
     
      Tell us briefly about your organization's mission:
     
      How did you first learn about NPower Indiana?
     
    NPower Mailing NPower Indiana Website
    Membership Kit NPower Event/Discussion Series
    Other Non-Profit, please specify below NPower Staff Member
    Funder, please specify below: Other Tech Assistance Provider
    News Item in/on:
    		 Other, please specify below
    Day of Service Invitation  
      What is your organization's area of focus?
     
    Arts & Culture Housing/Homelessness

    Civic/Community Development

    		 Health and Human Services
    Education Legal/Advocacy
    Environment Other, please specify below
    Youth

  2. NPower Indiana Services
    3.   Which NPower Services are you most interested in? (Check all that apply)
      Desktop Services
      Network Services
      Database Services
      Website Services
      Connectivity
      Cabling and Wiring
      Branded Software
      Hosted Services
      Volume Purchase Agreements
      Training and Education
      E-Commerce
      Technology Planning

  3. Primary Contact
    4. Please supply information about the person who will be NPower Indiana's primary point of contact with your organization.
    * Name :
      First name Last name
    * Title :
    * Address : (address 1)
    (address 2)
    (city) , (zipcode)
    * Phone : (i.e. 123-123-1234)
      Fax : (i.e. 123-123-1234)
      Email :

  4. Billing Contact
    5. Same as Primary Contact (proceed to section 5)
    Please supply information about the person who is the billing contact at your organization. This is the person who will receive and pay NPower Indiana invoices.
    * Name :
      First name Last name
    * Title :
    * Address : (address 1)
    (address 2)
    (city) , (zipcode)
    * Phone : (i.e. 123-123-1234)
      Fax : (i.e. 123-123-1234)
      Email :

  5. Executive Director
    6. Same as Primary Contact (proceed to section 6)
    Same as Billing Contact (proceed to section 6)
    NPower IN will occasionally hold events focused on the Executive Directors of local non-profits. We will use this information for invitations.
    * Name :
      First name Last name
    * Title :
    * Address : (address 1)
    (address 2)
    (city) , (zipcode)
    * Phone : (i.e. 123-123-1234)
      Fax : (i.e. 123-123-1234)
      Email :

  6. Board Chairman
    7. NPower Indiana will occasionally hold events focused on the Board Chairs of local non-profits. We will use this infomation for invitations.
    * Name :
      First name Last name
    * Place of Employment :
      Term Expiration Date : (i.e. mm/dd/yyyy)
    * Phone : (i.e. 123-123-1234)
      Email :

  7. Permissions
    8. * In response to inquiries from individuals, companies, foundations, and prospective customers about NPower Indiana members, we believe it would be useful to share our membership list with the public. What would this mean for your organization?


    • The NPower Indiana website will list current member organizations and be updated as new members join.
    • The NPower Indiana website may feature links to members' websites.

    * Would you like your organization and/or website listed?
    Yes             No
    Website address: Http://

  8. Membership Dues
    9. * Based on your organization's current operating budget, place a check in the appropriate box in the table below to indicate your Membership dues. (If this figure somehow misrepresents your organization's financial situation -- e.g., you are the regional office of a national non-profit organization or you are part of a larger, locally based organization but that organization is not joining NPower Indiana -- please give us a call.)
       
    Annual Dues
    Operating Budget over $5 Million    $450
    Operating Budget from $1 Million   -  $5 Million    $350
    Operating Budget from $250,000  -  $1 Million    $250
    Operating Budget from $50,000  -  $250,000    $150
    Operating Budget under $50,000    $  50

  9. Payment Information
    10.   * Based on this year's operating budget, I am mailing membership dues
    in the amount of $
      * Name:    * Title:      
       Date: 07/04/2004
       
     

    * Please select your method of payment:
    I am paying online by Credit Card.
    I am mailing a check together with the requested information below.

    Then send us the following:

  10. Agency brochure and/or annual report

  11. A copy of your most recent IRS 501(c)3 determination letter

  12. And mail to:

    13.                                  NPower Indiana
                                     Attn: Beverly A. Rella, Resource Director
                                     1405 E. Broad Ripple Avenue
                                     Indianapolis, IN 46220
      NPower Indiana membership services begin upon our acceptance of this application and receipt of your membership dues
     

 
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