Shop Our Store
Make a Donation
About Us
Board of Directors
Staff
In Memory of Mary Anne Moffa
Impact Report
News
Newsletters
Fellows Brochure
Fellows' Stories
Solidarity Series
Resources
Links
Job Postings
Contact Us
Photo Galleries
Fellowships
How to Apply
PBF Fellowship Positions
Fellowship Application Form
For Mentors
For Law Schools
Fellows Brochure
FAQ
Workers' Rights Conference
NLSWRC Home
Program Schedule
Student & Attendee Registration
Become a NLSWRC Sponsor
Employer & Allies Tables
FAQ
Awards Receptions
Regional Workshops
Home
>
Leadership Circle Membership Form
>
Uncategorised
>
Leadership Circle Membership Form
Leadership Circle Membership Form
First Name
*
Invalid Input
Last Name
*
Invalid Input
Title
Invalid Input
Organization / Business Name
*
Invalid Input
Address
*
Invalid Input
Invalid Input
City
*
Invalid Input
State
*
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Invalid Input
ZIP
*
Invalid Input
Work Phone
*
Enter a valid phone number: e.g. 123-456-7890
Mobile Phone
Invalid Input
Home Phone
Invalid Input
Email Address
*
Invalid Input
Please credit this membership as:
*
Personal Gift
Organization / Business Gift
Invalid Input
Choose Your Recognition Level
*
Pacesetter: $25,000+
Leader: $15,000 - $24,999
Champion: $10,000 - $14,999
Benefactor: $5,000 - $9,999
Defender: $2,500 - $4,999
Patron: $1,000 - $2,499
Invalid Input
I / We prefer to pay for this membership by
*
Check
Credit Card
Invalid Input
Invalid Input
Continue
Upcoming Events
Awards Receptions
Washington D.C. Awards Reception
May 15, 2025
View All Awards Receptions
Sign Up for Updates
Connect with us on