Membership Commitment Form for Existing Members

Payment (in the form of check or purchase order or a commitment date to pay) of membership dues in the amount of

Select Your DuesEntitlement and Insular Area: Under 50,000: $550Entitlement and Insular Area: 50,000 – 100,000: $940Entitlement and Insular Area: 100,001 – 250,000: $1,545Entitlement and Insular Area: 250,001 – 500,000: $2,000Entitlement and Insular Area: Over 500,000: $3,430———————–Alumni Members: $175Affiliate Member: $2,500Non-Entitlement Member: $375Subscriber Member: $375Student Member: $50

will be forwarded to NCDA*. You may also pay online after submitting your application. Expected payment date: .

First Name: *

Last Name: *

Title:

Agency:

Address:

City:

State:

Select a StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutWashington D.C.DelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissourriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming

ZIP:

Population:

Phone:

E-Mail Address: *

Web Site Address:

Statement Against Sharing NCDA Member Information or Soliciting NCDA Members

As an NCDA member, I agree not to share any materials or information produced for NCDA members, including but not limited to the following:

• Membership database or list
• Washington Report Newsletter
• E-mail alerts
• Any items on the Members Only page of the NCDA Website
• Log-in information
• Any other NCDA materials or information

Further, I agree not to solicit the NCDA membership in any manner.

Please type “Yes” to acknowledge that you have read and fully understand these requirements: