Apply For/Renew Membership

Download the membership application (PDF) and return to Drive Clean Indiana via email or by mail or fill out our online form below.

PLEASE FOLLOW THESE STEPS FOR ONLINE SUBMISSION

1) FILL OUT THE FORM BELOW

2) CLICK THE SUBMIT BUTTON TO SEND THE FORM TO DRIVE CLEAN INDIANA

3) SELECT YOUR MEMBERSHIP LEVEL IN THE DROPDOWN BOX BELOW THE SUBMIT BUTTON

4) CLICK “BUY NOW” TO BE DIRECTED TO PAYPAL TO SUBMIT YOUR ONLINE PAYMENT

Name*
First Last
Title*
Organization*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone*
Cell Phone
Email*
Website*
Secondary Contact Information
First Last
Title
Work Phone
Cell Phone
Email
Membership Level*
- Diamond ($10,000)
- Platinum ($5,000)
- Gold ($3,500)
- Silver ($2,000)
- Bronze ($1,000)
- Associate ($500)
Total
$0.00

Once you have filled out the application above, please choose an amount from the drop down below to submit your payment via PayPal.

Site Links