Membership Form

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Membership Form >

Fill in the form below to apply for membership to the Committee. When completed, click the "Submit" button to email it to the Committee. When the information is sent to the Committee, you will be taken to a page where you can make your membership payment, or other contribution, online. Annual Dues are $$35.00 for Regular Membership or $15.00 for Student Membership.

Membership: * New Member Renewal

Name: * First: * M.I.: Last: *

Address 1: *
Address 2:
City: * State: * Postal Code:
Country: *

Telephone Numbers

Home: Work: Fax:
Your Email Address: *

Information About Your Organization

Name: *
Accredited by: * ECOSOC DPI Neither
Address 1:
Address 2:
City: State & Postal Code:
Country:
Your Title / Position:
Organization Telephone Number: Fax:

Membership Dues and Contributions

Dues (Jan 1 - Dec 31): $35.00 Regular Membership or $15.00 Student Membership
+ Contribution to Virginia Hazzard Memorial fund
+ General contribution

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Total payment (processing will occur after you submit this form):

The NGO Committee on Ageing

Online Membership Form