NCoGS Membership Application 2013 11/1/13-10/31/14

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* 1. Name

Last Name

First Name

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* 2. Address

Street Address or PO Box

City

State

ZIP Code

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* 3. Phone Numbers Including Area Code

Work Phone

Cell Phone

Home Phone

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* 4. Email Address (please review for accuracy)

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* 5. Program Identifcation

Program Name

State

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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

Active Member: Those actively engaged in the operation of development of an existing governor's school program and those currently involved in setting policy in such schools.

Associate Member: Those interested in advancing the purposes of governor's schools who do not qualify for active membership.

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* 7. Membership Fee

$75 The first two members of a program pay $75 each; all additional members pay $25. Contact your program administrator to determine which fee applies to your membership.

$25 Applies to all additional memberships from the same program.

$10 Applies to full time students and alumni.

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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.

Yes

No (must specify reason below)

Explanation for non-payment

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

Administrator (Overall)

Administrator (Campus)

Administrative (Other)

Board Member

Faculty

Residential Staff

Support Staff

Other

Other (please specify)

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* 10. My position is:

Part-time

Full-time

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

Relationship / Interest

Position

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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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* 1. Name

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* 2. Address

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* 3. Phone Numbers Including Area Code

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* 4. Email Address (please review for accuracy)

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* 5. Program Identifcation

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* 6. Membership DetailsMembership 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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* 7. Membership Fee

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

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* 10. My position is:

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

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

* 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