DATE______________

CLUB NAME___________________________________________________________

CLUB ADDRESS________________________________________________________

NAME OF CONTACT PERSON_____________________________________________

CONTACT ADDRESS____________________________________________________

TELEPHONE DAYTIME_______________________ EVENING____________________

EMAIL ADDRESS________________________________________________________

OFFICE/POSITION CURRENTLY HELD_______________________________________

Payment of annual dues
   ANNUAL STATE DUES are due to be paid by August 31, 2007, for the 2007-2008 year.
Annual dues are $2.50 per member. The JOINING FEE for a NEW CLUB is $10.00, and must accompany your local member dues.
If your club is renewing its membership, and fails to do so by October 1, 2006, a $25.00 REJOINING FEE will be added to your dues.

PLEASE CHECK ONE OF THE FOLLOWING:
    1.  Annual Renewal (oneTime)            ______no fee
    2.  First time application                   ______$10.00/club
    3.  Annual renewal (delinquent)          ______$25.00/club

Local member dues:
The number of members currently registered in our local club is _________ X $2.50 each.

                                             TOTAL AMOUNT OF DUES_______________

PLEASE WRITE CHECK FOR THE TOTAL AMOUNT DUE, AND MAKE CHECK PAYABLE TO:
 

Please mail checks and this document to:
 

NCMOMS will appreciate your club's efforts to pay dues on time.