DUE January 31st

Only international dues are owed from each Junior Civitan club/member. Please complete the form below and remit your club’s international dues payment as follows:

Option 1: Make a check payable to Civitan International.

Civitan International
Attn: Junior Civitan Dues
P.O. Box 382857
Birmingham, AL 35238
*Please include the Junior Civitan club’s name and number of members with your check so that we can match it with the correct form. Please ensure you use the above address when remitting your form and check as our P.O. Box number was changed in 2021.

Option 2: Pay dues online.

After submitting this form, visit the “donate” tab found on the top right side of the website and fill it out appropriately. *Please include the Junior Civitan club’s name and number of members so that we can match your payment with the correct form.

Dues Form

Submitting this form is one part of the Dues process. To pay dues please send in a check or go to the Donate section of the website to pay online. Form and payment are due by January 31st.

School/Club Name:(Required)

Club Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

# of Club Members (full dues):(Required)

*Full dues = $12.00/person

# of Club Members (half dues):(Required)

*Members who have an intellectual/developmental disability qualify for half dues = $6.00/member

Total # of Club Members:(Required)

Total Amount of Dues Owed:(Required)

Full Dues = $12.00/member, Half Dues = $6.00/member

Advisor Name:(Required)

First Last

Advisor Email:(Required)

*Please ensure that this email address can receive external emails. We have experienced some school email addresses that reject our emails from being delivered.

Advisor Phone:(Required)

Co-Advisor Name:

First Last

Co-Advisor Email (if applicable):

*Please ensure that this email address can receive external emails. We have experienced some school email addresses that reject our emails from being delivered.

Co-Advisor Phone (if applicable):

Name of Sponsoring Civitan Club:(Required)

Sponsoring Club Liaison Name:(Required)

First Last

*This should be one representative from your sponsoring club who communicates with you.

Sponsoring Club Liaison Email:(Required)

Sponsoring Club Liaison Phone:(Required)

Upload Club Roster(Required)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, xls, xlsx, Max. file size: 100 MB.

Please upload your club roster that includes all officers and members along with their email addresses (at minimum).

Additional Comments (optional):