NCNGA Membership Application 7410 Chapel Hill Road - Raleigh, NC 27607 (919) 851-3390 info@ncnga.org Please type (or print clearly) Name: Address: City:
State:
Zip:
Unit:
Telephone:
Social Security Number: X X X
XX
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E-mail Address: I prefer to receive my magazine via e-mail
***************************************************** Membership Type (please check one):
**YOU CAN APPLY AND PAY ONLINE NOW!**
Annual ($15) (1 Jan - 31 Dec)
just visit our website www.ncnga.org
Life ($250) *Life dues installment option
(Life dues may be paid in quarterly installments of $62.50 each. The first installment of $62.50 must accompany your application. Life dues (and any portion paid towards life membership)are non-refundable.)
Credit Card Payment:
(If paying by credit card, a $3 processing fee will be added to your total)
Name on Card: Card Number: Expiration Date:
Security Code:
(on back of most cards)
Signature: YOU CAN MAIL THIS FORM TO THE ADDRESS LISTED ABOVE OR E-MAIL IT TO THE E-MAIL ADDRESS LISTED ABOVE