NSELA - Membership Application

Membership Application

Please complete the following information if you plan on paying by credit card only. If you would like to pay by check you must download the membership brochure and mail in the form as indicated.

Upon clicking Submit, you will be forwarded to a page which explains your payment options by credit card. Contact the Membership Committee Chair with any questions.

Name:
Position:
Institution:
Office Address:
Home Address:
Address to be listed in the directory and to which mail will be sent:	home office
Home Phone:
Office Phone:
Office Fax:
Email:
I am interested in becoming :	a committee member an elected official (For a list of offices and committees visit the job descriptions page.)
Areas of consulting interest:
I am a	new member ($45) renewing member ($45) new retired member ($15) renewing retired member ($15)
I will be paying by	Check Credit Card (additional $3 processing fee)
Upon clicking submit you will be forwarded to a page with payment information.