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NACCTEP Membership and Renewal Application

* = Required Field

Are you joining as a new member or renewing your current membership?*

I am joining as a new member.

I am renewing my current membership.

Please select the type of membership you are requesting.

MEMBERSHIP BONUS! Conference registration includes 2016-17 NACCTEP Individual membership.
MEMBERSHIP PLAN	MEMBERSHIP FEE	CONFERENCE REGISTRATION FEE	DISCOUNTS	ADDITIONAL FEES
Institutional Member	$300	$400	$100 limit 3 representatives	$75 each representative after 3
Educational Partner	$300	$400	$100 limit 3 representatives	$75 each representative after 3
Corporate Membership	$500	$400	$100 limit 3 representatives	$75 each representative after 3
Individual Membership	$110	$400	$110	-
Student Membership	$35	-	-	-

Institutional, Educational and Corporate Membership includes up to three representatives.
Additional representatives can be added for $75 each.

Please indicate below the number of representatives you are registering today.
More representatives can be added at a later date.

	One Representative
	Two Representatives
	Three Representatives
	Three representatives + 1 Additional representative
	Three representatives + 2 Additional representatives

Please complete the following information for each of your members.
If you have more than the allotted members, please contact NACCTEP at 480-517-8074.

Primary Representative
Prefix:*	Dr. Mr. Mrs. Ms.
First Name:*
Last Name:*
Position/Title:*
College:*
Campus:
College/ Department Web Site :
College President:
Address:*
City:*
State:*
Zip:*
Work Phone Number:*
Fax Number:
Email Address:*

Representative #2
Prefix:	Dr. Mr. Mrs. Ms.
First Name:
Last Name:
Position/Title:
College:
Campus:
Address:
City:
State:
Zip:
Work Phone Number:
Fax Number:
Email Address:

Representative #3
Prefix:	Dr. Mr. Mrs. Ms.
First Name:
Last Name:
Position/Title:
College:
Campus:
Address:
City:
State:
Zip:
Work Phone Number:
Fax Number:
Email Address:

Additional Representative #1
Prefix:	Dr. Mr. Mrs. Ms.
First Name:
Last Name:
Position/Title:
College:
Campus:
Address:
City:
State:
Zip:
Work Phone Number:
Fax Number:
Email Address:

Additional Representative #2
Prefix:	Dr. Mr. Mrs. Ms.
First Name:
Last Name:
Position/Title:
College:
Campus:
Address:
City:
State:
Zip:
Work Phone Number:
Fax Number:
Email Address:

Payment Method*

I am using a Purchase Order (PO).

PO#

Please fax a copy of the PO to 480.731.8786.
Maricopa Community Colleges Tax ID # is 86-0185552.

I am sending NACCTEP a check.

Please submit payment by check in U.S. dollars payable to

NACCTEP
2323 West 14th Street
Tempe, Arizona 85281-6942

I am using a Credit Card.

Please call NACCTEP at 480-517-8074 to pay over the phone or fax your credit card information (name, credit card number, expiration date) to 480-377-4713.

When paying by credit card, your statement will reflect a charge from either Maricopa Community Colleges or MCCCD.

Please review this form carefully before continuing. Make sure all information provided is correct.
Upon receipt of membership application, the Primary Member will receive a confirmation.

If you have any questions, please contact NACCTEP at 480.517.8074.

PRINT THIS FORM FOR YOUR RECORDS BEFORE CONTINUING!