Membership Sign-Up Form Fields marked with "*" are required. Agency Information Please complete all sections. The address, general email address and website will be used to update member agencies on Abilities Manitoba’s website. Please note that your agency will be responsible to notify Abilities Manitoba of any changes to this information. If you are experiencing difficulties completing your membership form, please contact firstname.lastname@example.org Agency Name * Address * City / Town * Postal Code * General Email Address * Phone Number * Website Executive Director/CEO Name * Email Address * Annual Operating Budget of Agency * (do not enter commas, periods, etc.) $ We receive CLdS funding * YesNo Annual Community Living Disability Services(CLdS) Funding From All Sources * (do not enter commas, periods, etc.) $ Your Fee: $ Note: If your organization is funded by CLdS, your membership fee is 0.04% of that funding. The minimum membership fee is $150.00 and the maximum fee is $10,000. We will adjust invoices accordingly Your Fee: $ Note: If your organization is not funded by CLdS, your membership fee is 0.04% of your annual budget. The minimum membership fee is $150.00 and the maximum fee is $10,000. We will adjust invoices accordingly I certify that this organization: * Is a non-profit agency that provides or is planning within the next year to provide services to Manitobans with intellectual disabilities. Supports the mission, vision & values of Abilities Manitoba. Is applying for a new/renewed membership with Abilities Manitoba. Will provide statistical information from your agency within 6 weeks of membership renewal. Payment Schedule - please select a payment option * (An invoice will be mailed to you shortly) One time payment (April)Two payments (April and October)Quarterly payments (April, July, October, January) Final approval of this membership application will be based on review of application & receipt of the applicable membership fee. Upon approval an invoice will be emailed and payment can be made by cheque. Memberships expire March 31 annually.