WPDHAC Nonprofit and Corporate Supporters Program Application Form

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This application form is for nonprofits and corporations who would like to enroll or renew their enrollment in Western Pennsylvania Disability History and Action Consortium's Supporters program.

Please note: after your application is processed, we will send you a welcome email with an attached invoice. As will be instructed on the invoice, checks will be made out to Achieva, our fiscal sponsoring organization.

Are you a new or renewing Supporter?
*

New

Renewing

Unsure

First Name
*

Last Name
*

Job Title
*

Organization or Company Name (please use the full name rather than the acronym)
*

Email address
*

Phone number
*

Link to the organization or company website or page (full URL)

Mailing Address Line 1
*

Mailing Address Line 2 (optional)

City
*

State
*

Zip Code
*

Please choose the desired Supporters program level. (To view benefits for each level again, please visit https://www.wpdhac.org/supporters-program/) *

Nonprofit Supporter ($500/year)

Nonprofit Advocate ($1,000/year)

Nonprofit Patron ($2,000/year)

Nonprofit Ambassador ($4,000/year)

Corporate Supporter ($750/year)

Corporate Advocate ($1,250/year)

Corporate Patron ($2,500/year)

Corporate Ambassador ($5,000/year)

Opt Outs

My nonprofit or company DOES NOT wish to be included in WPDHAC's annual report

My nonprofit or company DOES NOT wish to be listed as a Supporter on WPDHAC's website

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