MEMBERSHIP FORM AND DUES STATEMENT July 1, 2016 to June 30, 2017
PART 1. CONTACT INFORMATION Name: Organization: Title/position: Office Mailing Address: Office Email: Office Phone Number: Personal Mailing Address: Personal Email: Mobile Number:
Other Number:
Preferred Address:
Office
Personal
Phone:
Office
Personal
Email:
Office
Personal
Other
Communication Opt-In: JMLBA sends a weekly e-newsletter and periodic emails related to JMLBA and other events and programming we believe would be of interest to JMLBA members and supporters. We may use a third-party, such as, but not limited to, Constant Contact, to send these email messages. In the past, everyone has wished to receive these emails. JMLBA may send text reminders of our upcoming events. These will be infrequent reminders, e.g., on the day before or day of an upcoming JMLBA meeting or event. On occasion, we may send text reminders of non-JMLBA events, such as Election Day. We may use an auto-dialer or third-party to send these text messages. You are solely responsible for any charges associated with receiving these text messages. You are not required to consent to emails or text messages as a condition of joining JMLBA or participating in JMLBA programs. By selecting "YES" below, you authorize JMLBA to deliver these types of messages using these methods to the email address and/or mobile number you provided herein. Do you consent to receive email messages at your preferred email address?
Yes
No
Do you consent to receive text messages at your mobile number listed above?
Yes
No
JMLBA Membership Application 2016-2017
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PART 2. ABOUT YOU Practice Area(s): Member Type:
Renewing
New
Committee Interest: Communications
Community Activism
Fund Development & Finance
Judicial Screening & Special Initiatives
Membership & Social Outreach
Mentoring
Professional Development
Solo/Small Firm Practice
Technology & Social Media
Other:
Should we list you in our solo/small firm/non-profit referral directory?
Yes
No
PART 3. PAYMENT Life Member ($1000)
Law School Student (Free)
Private Practice Attorney/J.D. ($50)
2015 Law School Graduate (Free)
Government/Academic Attorney/J.D. ($25)
2016 Law School Graduate (Free)
Solo/Non-Profit Attorney/J.D. ($25) *How do you plan to pay: Online Credit Card By Mail Check By Mail To pay pay by by credit credit card, card, use usePaypal Paypal(directions (directionsbelow) below)or oremail emailthis thiscompleted completedform formtoto To
[email protected]. To pay by check, mail this completed form with your payment. payment.
[email protected]. To pay by check, mail this completed form with your Online: Visit http://www.jmlba.co/ to pay via Paypal ● You do NOT need a Paypal account to pay online using the link above ● If the name on your Paypal account or credit card does NOT match the name of the member for whom you are paying (e.g., maiden name, company name, boss, etc.), please click "Add special instructions to the seller" and include the member's name. This makes it easier for us to match your payment to your membership application to ensure you are confirmed as a member as quickly as possible. Visa®/Mastercard®
Credit Card Offline:
American Express
Discover
Name as it appears on Card: Account Number:
Exp. Date:
Signature: Your signature here authorizes us to charge the total cost of your membership.
Checks: Please make payable to and mail to John Mercer Langston Bar Association Attn: Treasurer 175 S. Third Street, Suite 200 Columbus, OH 43215 *Payment of dues or other contributions to JMLBA are not tax deductible as charitable contributions for income tax purposes. They may, however, be tax deductible as ordinary and necessary business expenses to the extent not allocated to lobbying expenditures. JMLBA Membership Application 2016-2017
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