Name

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* 1. Name

Address

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* 2. Address

Phone Numbers Including Area Code

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* 3. Phone Numbers Including Area Code

Email Address (please review for accuracy)

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* 4. Email Address (please review for accuracy)

Program Identifcation

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* 5. Program Identifcation

Membership Details
Membership runs from November 1 to October 31 of each calendar year.

For a more expanded definition of membership categories please visit www.ncogs.org

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* 6. Membership Details
Membership runs from November 1 to October 31 of each calendar year.

For a more expanded definition of membership categories please visit www.ncogs.org

Membership Fee

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* 7. Membership Fee

Payment
I am mailing payment to: Joshua Brown, GPGC (NCoGS); 330 Wilkinson Street, Mandeville, LA 70448. If you have questions about payment please email me at director@gpgc.org or call my cell: 337-540-7280. If you would like to pay by credit card please use our paypal address: paypal@giftie.org.

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* 8. Payment
I am mailing payment to: Joshua Brown, GPGC (NCoGS); 330 Wilkinson Street, Mandeville, LA 70448. If you have questions about payment please email me at director@gpgc.org or call my cell: 337-540-7280. If you would like to pay by credit card please use our paypal address: paypal@giftie.org.

Relationship to Governor's School: Select any that apply

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* 9. Relationship to Governor's School: Select any that apply

My position is:

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* 10. My position is:

If you are not involved with a governor's school, please indicate your relationship or interest.

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* 11. If you are not involved with a governor's school, please indicate your relationship or interest.

If you are employed elsewhere please list employer, position and complete business address.

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* 12. If you are employed elsewhere please list employer, position and complete business address.

Please print your document at this time. After you have submitted the document you will not be able to print.

PLEASE NOTE: If there are errors in your application you will remain on this page and there will be error messages above the incomplete entries. Please correct the errors and click the submit button again.

If you have any questions or issues with this application please contact Joshua Brown at director@gpgc.org

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