National Guardianship Association, Inc.
Membership Application
National Guardianship Association		 174 Crestview Drive, Bellefonte, PA 16823-8516
Toll Free: 877-326-5992
Email: info@guardianship.org
 
 

I Am Applying For:

Individual Membership Organization Membership Family/Volunteer/Retired Membership
The membership year runs from January 1 - December 31. Membership dues are payable by January 1 each year.

Please complete the following information as an individual member OR as the primary contact for an organization. (Organizations paying
for additional memberships should also submit just the information section of this form for each additional person.) If you are applying
as a family or volunteer guardian, or as a retired guardian, please complete all the information that seems appropriate.

Name: Title:
Company/Organization/
Agency Name:
Address:
City: State: Zip Code:
Phone: Fax: Email:
Website: I am I am not a member of a state guardianship association.

Notice: By including your email and fax information you are agreeing to accept electronic notices and news as part of your membership. Providing your
email address for use by NGA is not the same as signing up for the Listserv, a member benefit that allows members to communicate with each other. In
turn, NGA pledges to respect your privacy and will do its utmost to protect you from unsolicited communications by third parties.

Complete the sections below to add Organization - Additional Members. If you don't have additional members to add, click here to add skip to the next section.

Name: Title:
Company/Organization/
Agency Name:
Address:
City: State: Zip Code:
Phone: Fax: Email:
Website: I am I am not a member of a state guardianship association.

Notice: By including your email and fax information you are agreeing to accept electronic notices and news as part of your membership. Providing your
email address for use by NGA is not the same as signing up for the Listserv, a member benefit that allows members to communicate with each other. In
turn, NGA pledges to respect your privacy and will do its utmost to protect you from unsolicited communications by third parties.

Name: Title:
Company/Organization/
Agency Name:
Address:
City: State: Zip Code:
Phone: Fax: Email:
Website: I am I am not a member of a state guardianship association.

Notice: By including your email and fax information you are agreeing to accept electronic notices and news as part of your membership. Providing your
email address for use by NGA is not the same as signing up for the Listserv, a member benefit that allows members to communicate with each other. In
turn, NGA pledges to respect your privacy and will do its utmost to protect you from unsolicited communications by third parties.

Name: Title:
Company/Organization/
Agency Name:
Address:
City: State: Zip Code:
Phone: Fax: Email:
Website: I am I am not a member of a state guardianship association.

Notice: By including your email and fax information you are agreeing to accept electronic notices and news as part of your membership. Providing your
email address for use by NGA is not the same as signing up for the Listserv, a member benefit that allows members to communicate with each other. In
turn, NGA pledges to respect your privacy and will do its utmost to protect you from unsolicited communications by third parties.

I Am Employed In (check one)

For-Profit Business Non-Profit Organization Government Agency Court System
Retired Guardian Not Employed in Guardianship Profession Other ( )

Please Describe the Type of Services You Provide (check all that apply)

Guardian of Person Legal Services Representative Payee
Guardian of Estate Rehabilitation Services Day Treatments
Guardian of Minor Fiduciary Judge/Judicial
Case Management Residential Care Other ( )

Dues Payment:

Please allow 7 to 10 business days for your application to be processed following receipt by the NGA Business Office.
Check here if you want an emailed receipt when payment is processed. Our Federal ID # is 36-3591860

$180 - Individual Membership
$260 - Organization Membership, plus additional members of my organization @ $110 each
  (Organizations paying for additional memberships should also submit the information section of this form for each additional person.)
$ 60 - Family, Volunteer, or Retired Membership

Optional Advocacy Donation:

You have the option to make a separate additional voluntary contribution to support NGA’s advocacy efforts as part of your membership application.

In addition to my dues payment I want to make a voluntary contribution of $ in support of NGA’s advocacy efforts.
Please specify if this contribution is to Honor Memorialize

My Total Payment for Dues + Advocacy Contribution is: $
 
Credit Card Information:
Name on Card:
Account Number: 16 characters left.
PLEASE MAKE SURE YOU HAVE ENTERED A 16 DIGIT VALID CREDIT CARD NUMBER
Select Expiration Date:
     
     
       

Credit Card payment will be processed within 7-10 business day.

Thank you