Member Application

Date
Name of Primary Contact*
Title
Company/Organization*
Mailing Address*
Address 2
City*
State*
Zip Code
Email*
Website Address
Telephone*
Fax
I have read and agree to adopt the NNCG Code of Ethical Conduct
Services/Areas of Expertise (check all that apply):	Communications Evaluation Family Dynamics Grantmaking and Staff Training Governance Information Technology Leadership & Leadership Transition Mission and Program Development New Foundation Design Public Policy and Advocacy Retreat Facilitation Strategic Planning Other
If other, please explain:
Types of Grantmakers Served (check all that apply)	Community Foundations Corporate Giving Programs Family Foundations Government Grantmakers Private Foundations Public Charity Grantmakers Other
If other, please explain:
Number of years serving grantmakers as a consultant*
Geographic area(s) you serve
Payment Information:
Membership Type*	Member-Individual $350 Member-Institution/Firm $1,000 (up to five individuals) Associate Member-Individual $350 Associate Member-Institution/Firm $1,000 (up to five individuals) Affiliate Member-Individual $350 Affiliate Member-Institution/Firm $1,000 (up to five individuals)
Additional Contribution (to help launch NNCG)
Total Payment
Payment Method	Mastercard Visa American Express Discover
Account #
Exp.
Name as it appears on your card
List five grantmaking clients within the last three years: Required for full members; optional for Associate and Affiliate Members
Organization Name
Contact Person
Title
Phone
Email Address
Organization Name
Contact Person
Title
Phone
Email Address
Organization Name
Contact Person
Title
Phone
Email Address
Organization Name
Contact Person
Title
Phone
Email Address
Organization Name
Contact Person
Title
Phone
Email Address
IF JOINING AS AN INSTITUTION OR FIRM ONLY: You are able to list up to four employees in your institution or firm who will participate as part of your membership. For each person to be recognized as a “full member,” please list 5 grantmaker clients with whom they have worked within the past 3 years. (Not necessary for associate or affiliate members.)
Name of Member 2
Title
Company Organization
Mailing Address
City
State
Zip Code
Email Address
Telephone
Fax
List five grantmaking clients within the last three years:
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email

Name of Member 3
Title
Company Organization
Mailing Address
City
State
Zip Code
Email Address
Telephone
Fax
List five grantmaking clients within the last three years:
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email

Name of Member 4
Title
Company Organization
Mailing Address
City
State
Zip Code
Email Address
Telephone
Fax
List five grantmaking clients within the last three years:
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email

Name of Member 5
Title
Company Organization
Mailing Address
City
State
Zip Code
Email Address
Telephone
Fax
List five grantmaking clients within the last three years:
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email
Organization
Contact
Phone
Email