NSACoop: New Member Enrollment Application

NEW MEMBER ENROLLMENT APPLICATION

Print an application form

Name (First/Middle/Last):

Salutation (name you prefer to be called by if different from above):

I was referred to NSAC by (member name):

Chapter(s) I want to join (Refer below):

I prefer correspondence to go to my: Firm Address Home Address

Are you a former member of NSAC? Yes No

Company Information:

Job Title:
Firm Name:
Mailing Address:
City:	State: Zip:
Country:
Address, City, State, Zip For FEDEX, UPS, etc (if different from above)
Work Phone + Extension:
Fax:
Toll free number:
Email:
Website:
CEO or General Manager's Name:
Where are your firm's customers?
CO-OP Type : If your firm is not a cooperative, please choose not a cooperative.	If you chose "other", please describe below:

Home Information: We do not give this information to other members or to non-members without your permission. We need this information in case we are unable to reach you at your firm or you leave your form and we can’t get a forwarding address from them. It will not be accessible to others on the website unless it is the only address you give us or it is your preferred address for mailings.

Home Address:
Home City:	State: Zip:
Home Phone:
Cell Phone:
Email:

Professional Information:

Are you a CPA? Yes No

Occupation

If other, please specify:

Number of years in a cooperative activity or providing professional support to a cooperative activity:

Other relevant professional certifications: (enter in the text box provided below)

Demographic Information: (optional)

Date of Birth: Male Female

Name of school:	City/State:	Degree and Year:

Each application MUST be accompanied by a check or charge for both (1) national and (2) chapter dues. Dues are non-refundable. Retired members are not required to pay chapter dues. See Membership Dues and Chapter Dues Below.

Please charge my payment in the amount of $ to my Visa MasterCard AMEX

Card Number: Expiration Date:

Name on credit card:

Credit card billing address: Firm Address Home Address Other:

Approval of this application is subject to final endorsement by the Executive Board.

Membership Types:

All memberships are individual memberships and are not transferable.

REGULAR: To be eligible for regular membership, an individual shall be employed by or affiliated with a cooperative association, be engaged in providing professional services for cooperatives, or shall otherwise be engaged in the furtherance of cooperative principles. The national annual membership service fee is $150.00 and covers 1 year of membership from the date enrolled. NSAC membership dues MUST include payment of national membership service fees plus applicable chapter dues (listed below).

RETIRED: To be eligible for retired membership, an individual must have a minimum of five years active membership in good standing, have reached age 55, and be retired from active business under provisions of a formal retirement plan or through amicable arrangement with his or her employer which results in a complete serverance or material reduction in compensation, or have retired because of permanent disability. The national membership service fee is $50; there are no chapter dues required

CHAPTER MEMBERSHIP AND DUES

Chapter membership is required as a condition of membership in NSAC. Twelve chapters have been organized using state boundaries as set forth below. Members usually affiliate with the chapter covering the state in which they live or work. However, NSAC recognizes that for professional, geographic or other reasons members may prefer to affiliate with a different chapter or with more than one chapter.

Dues are assessed on the basis of all chapters chosen. Please designate on page 1 the chapter(s) in which you want to hold membership. If no choice is made, a chapter assignment will be made based on address.

CHAPTERS AND CHAPTER DUES

Capitol (DE, DC, MD, PA, PR, VA, WV, CT, ME, MA, NH, NJ, NY, RI, VT)
Electric Cooperative (nation-wide)
Far Western (AZ, CA, HI, NV, UT)
Great Lakes (MI, WI)
Mid-Central(IN, KY, OH, TN)
Mid-West (CO, KS, NE, NM, OK)
Mississippi Valley (AR, IA, IL, MO, MS)
North Central (MN, ND, SD)
Pacific Northwest (AK,ID,MT,OR,WA,WY)
South Atlantic (AL, FL, GA, NC, SC)
Texas (LA, TX)

$20
$15
$20
$10
$ 5
$10
$10
$10
$20
$30
$10