Membership Application

Download Print/Mail version of application form

All memberships are individual memberships and are not transferable.
To be eligible for regular membership, an individual shall be employed by or affiliated with a cooperative association, be engaged in providing professional services for cooperatives, or shall otherwise be engaged in the furtherance of cooperative principles. The national annual membership service fee is $175.00 and covers 1 year of membership from the date enrolled. NSAC membership dues MUST include payment of national membership service fees plus applicable chapter dues (listed below).

Chapter membership is required as a condition of membership in NSAC. Twelve chapters have been organized using state boundaries as set forth below. Members usually affiliate with the chapter covering the state in which they live or work. However, NSAC recognizes that for professional, geographic or other reasons members may prefer to affiliate with a different chapter or with more than one chapter.

Name (First/Middle/Last):
Salutation (name you prefer to be called by if different from above):
I am: Male   Female
I was referred to NSAC by (member name):
Are you a former member of NSAC? Yes     No

Please select at least one chapter you would like to join from the list below: (you may join multiple chapters)
 Chapter Name States CoveredDues
Capitol    DE, DC, MD, PA, PR, VA, WV, CT, ME, MA, NH, NJ, NY, RI, VT    $20
Electric Cooperative    Nationwide    $25
Far Western    AZ, CA, HI, NV, UT    $20
Great Lakes    MI, WI    $10
Mid-West    CO, KS, NE, NM, OK    $10
Mississippi Valley    AR, IA, IL, IN, KY, MO, MS, OH, TN    $10
North Central    MN, ND, SD    $10
Pacific Northwest    AK,ID,MT,OR,WA,WY    $20
South Atlantic    AL, FL, GA, NC, SC    $30
Texas    LA, TX    $10
Canada    Forming    $0

Contact Information
Job Title:
Firm Name:
Mailing Address: (please no PO Boxes)
City:   State:   Zip:
Country:
Work Phone + Extension:
Fax:
Toll Free Number:
Email:
Website:
CEO or General Manager's Name:
Where are your firm's customers?
CO-OP Type :
If your firm is not a cooperative,
please choose not a cooperative.


If you chose "Not Listed ", please describe below:

Professional Information
Are you a CPA? Yes     No
Occupation
If other, please specify:
Number of years in a cooperative activity or providing professional support to a cooperative activity:
Comments:

Payment Information
Each application MUST be accompanied by a check or charge for both (1) national and (2) chapter dues.
Total to Charge: $

Payment Method: Invoice Firm or Charge My Visa Master Card American Express
Credit Card Number:  
Card Expiration Date: (mm/yyyy)  
Name on Card:  
 
What is 10 plus 10?  (Anti-Spam Measure)

Approval of this application is subject to final endorsement by the Executive Board.