Page 2 - NAGC 67th Annual Convention Reimagined! Preliminary Program

Affiliate Membership
Application

Renew Online at www.nagc.org

 Renewal #
Institute/Organization ______________________________________________
Address __________________________________________________________  Yes, list our organization contact information
on the shared group list and the NAGC website
City/State/Zip ______________________________________________________________ under "Gifted by State."
 Yes, list our contact information on the NAGC
Phone _______________________________(h) __________________________________(w) website under the "Gifted by State" ONLY.
Website _____________________________________________________________________  I do not wish to list our state organization on
the shared roster
Organization E-mail __________________________________________________________
Questions regarding membership, please contact Adriane
Primary Contact ______________________________________________________________ Wiles at awiles@nagc.org or Denise Weathers at
Title ________________________________________________________________________ dweathers@nagc.org. All other questions, please contact
William Knudsen at wknudsen@nagc.org.
Primary E-mail ________________________________________________________________

1. Affiliate Membership Dues Affiliate Membership Benefits Include:
Affiliate Membership Dues
(Scaled price by database/paid membership size) • One complimentary NAGC Premier
membership for use by designated affiliate
officer ($119 value)
 Affiliate Membership size up to 250 members $450
• Two electronic access only memberships
for use by designated affiliate officer
 Affiliate Membership size 251-999 members $550 ($200 value)
• One designated state affiliate officer receives
 Affiliate Membership size 1,000 or more members $600 $100 off an NAGC Annual Convention
Registration
• One complimentary registration for two
2. Consider a Donation: (Optional) affiliate meetings per year (approx. $450
value).
• Membership Rebate Program ($10 rebate for
Donation members that sign up using state affiliate
 Please consider a donation to assist in NAGC’s Amount code.)
efforts to increase awareness of the needs of • Media advice
high-ability learners. NAGC is a 501(c) (3) non- • Dedicated staff contact
profit organization. Your donation to NAGC is • Affiliate micro-site
tax deductible to the extent the law allows. o Advocacy tools & resources
o Convention/meetings information
3. Payment Calculation and Information
(Renew online at nagc.org if there is no change to membership dues.) Membership Cancellation by Affiliate
Cancellations will be accepted via e-mail to
awiles@nagc.org or dweathers@nagc.org and must
0
Membership $__________ Donation $__________ Total $ _______________ be received by the stated cancellation deadline.
 Full Payment  3-month installment (first payment must accompany • Membership cancellations received within
renewal) $__________________________ 14 days of renewal will receive a refund less
$50 service fee.
 AMEX  Discover  Mastercard  Visa • Cancellations received after the stated
deadline will not be eligible for a refund.
 Check (payable to NAGC)  Purchase Order # __________(attach original PO) • Membership is not transferrable.
Name on Card: ______________________________________________________
Installment Payments:
Card No.: _______________________________________________________
• If the second or third membership
Exp. Date: ______Card Verification Code: ________Billing Zip Code: ____________ installment is not paid, the membership will
be cancelled.
Signature: _______________________________________________________________________