*1.Organization Name(Required.)

2.Name of Person Submitting Form

3.Email Address

4.Estimated Assets as of December 31, 2024

5.Average Payout
2023, 2024 and projected 2025 payout
GWP dues are based on a three year average of your giving. Add the totals for each year and divide by three to get your average payout.

*6.Dues Region(Required.)

Location in Allegheny County

Location in Collar County Region

Location Outside Ten-County Region

*7.County(Required.)

*8.Calculated Dues

• Funders in Allegheny County and Ten-Collar County Region pay total calculated amount.
• Funders located outside of Ten-County Collar Region pay for a basic membership

(Required.)

9.Optional Leadership Gift

10.Final Dues Amount

*11.Payment Information(Required.)

Please send invoice

Will pay via e-payment (highly encouraged)

Will send check

Other (please specify)

12.Additional Comments
Use this field for any additional comments regarding your online membership submission form.