:s ec ne re fe rr ek a m tn ar G

Check here if this member is a new representative from an NNCG institutional member.
MEMBERSHIP APPLICATION
Name of Primary Member:
Title:
Company/Organization:
Mailing Address:
City/State/Zip Code
Email Address:
Website Address:
Telephone:
Fax:
I, the undersigned, have read and agree to adopt the NNCG Code of Ethical Conduct.
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Date
N ame
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Select one of the following:
 Full Member—Institution/Firm (Please complete Reference section below)
 Associate Member—Institution/Firm
 Affiliate Member—Institution/Firm
Grantmaker references: List five grantmakers for whom you have provided consulting services. Indicate two
who will serve as your references to be contacted by NNCG. Please provide the grantmaker’s name, contact
person, phone number & email. (Not necessary for associate or affiliate members.) NNCG keeps this information
confidential and uses it solely to determine the fulfillment of membership criteria. If for reasons of client
confidentiality you cannot share this information, please contact our office at
[email protected]
Organization
1.
2.
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5.
Contact
P h on e
Email