HLC Invoice - Homeless Leadership Coalition

Membership Dues Invoice

Use this form to make a secure online payment for your HLC Membership Dues. Or, fill out a paper invoice and send with a check payable to COIC.

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Name*

(Primary Contact for Organization)

First Last

Name of Agency/Entity/Organization or Individual*

Email*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Membership Dues*

Organizations with $500,000+ budget ($250/year)

Organizations with a budget up to $499,999 ($75/year)

Faith Partners ($50/year)

Individuals or Families ($25/year)

Waiver Code

A membership dues waiver is available on request. Link to Dues Waiver Request Form.

Total

Payment Details*

All major credit cards accepted - including Visa, Mastercard, American Express, and Discover. Payments are processed by Square.

Cardholder Name

Card Details