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Application for Membership

Directions: You may either print out a blank printer-friendly version in PDF format, or type your answers in the form below, then use your browser's print button to print a completed application. Then, mail your application, along with the necessary payment, to the address shown below.

Return to: Membership Chairman
NCCAA
4428 Louisburg Road, Suite 101
Raleigh, NC 27616-4335
Select One:
Mr.   Mrs.   Miss   Ms.
Full Name of Applicant:
Title/Program:
Agency/Company:

Mailing Address:

Street Address:

City:  State:  Zip Code:

Phone Number: ( ) -
Fax Number: ( ) -
Email:
Date of Application: / /
Type of Membership:

Please enclose check for correct amount:

Agency Membership $1,407.00

Limited Agency Membership $305.00

Lifetime Individual $105.00

Individual $14.00

Senior Citizen (60 and over) $7.00

Sustaining Members:

  1-10 Employees $158.00

11-20 Employees $263.00

21+ Employees $525.00

Organization Affiliation:

CAP

LPA

Other __________________

State

Religious

 

Organization Name and Address:

Street Address:

City:  State:  Zip Code:

Applicant's Signature: Electronic Signature (Check Empty Box Here to Enter Into Binding Obligation*)

_______________________________________________________________
Who Encouraged You to Join NCCAA?
 












 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



*ELECTRONIC SIGNATURES
In accordance with federal law, the parties shall execute this Agreement electronically Ð binding the parties to the same degree as a handwritten signature Ð by using the following process to create an electronic symbol signifying intent to be legally bound. Each party must fill in the name, title, and date below, and check the open box at the end of the line marked ÒElectronic Signature (Check Empty Box Here to Enter Into Binding Obligation)*.Ó This Agreement shall not be binding on either party until both parties have electronically executed versions of the Agreement that are identical (apart from the electronic execution) and delivered the same to the other party by electronic mail as an attachment. Each party shall retain a paper copy of the electronic mail and attached executed Agreement received from the other party.



© 2008 North Carolina Community Action Association

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