Membership Form Member Organization Information:Organization Name:* Organization Website Address(to be linked to on the KPT website) Organization Logo: Drop files here or Select files Max. file size: 512 MB, Max. files: 5. Contribution Levels: Platinum: multi-year commitment of $30,000+ Gold: $10,000 - $19,999 Silver: $2,500 - $9,999 Bronze: $1,000 - $2,500 Affinity: $1,000 Membership Contribution Amount:*Payment Schedule:* Method of Payment:* Online (Paypal) Paper Check Mailed to KPT Receipt of Contribution*Do you need an invoice for this contribution? A W-9 will be sent to you for your records. Yes, send me an invoice. No, the W-9 is sufficient. Contact Information for Membership CorrespondenceName* First Last Address* Street Address (include Suite, Floor, etc.) City State / Province / Region ZIP / Postal Code Email* Phone*All memberships will renew. Invoices will be sent in November. For more information contact: Charlene Heydinger, Executive Director PO Box 200368, Austin, Texas 78720-0368 512.469.6184 | Charlene.Heydinger@keeppace.org www.KeepingPACEinTexas.orgCommentsThis field is for validation purposes and should be left unchanged.