Deadline: April 30, 2017

  • Affiliate Membership Renewal Checklist 2017

    Affiliate Membership is a status of Membership separate from and different than either Individual or Organizational Membership in NCPG. Affiliate Members are non-profit organizations that support and implement the purpose, mission and goals of the NCPG, and serve as the official representative of NCPG in their respective state(s).

    The goal of the NCPG Affiliates Membership program is to have an active and effective Affiliate chapter in each state, providing meaningful programs and services to people affected by problem gambling. All affiliates are required to meet or exceed the following standards.


    At all times during its membership, an Affiliate Member is expected to:
    1. Have a principal office in the state it represents and maintain a working phone number and email address;
    2. Be legally qualified as a Federal 501(c)(3) non-profit entity and meet all required city, state or federal business and nonprofit requirements;
    3. Have a Board of Directors that represents a broad cross-section of stakeholders on gambling issues and convenes at least one time per year;
    4. Have a written policy statement that the organization is neither for nor against legalized gambling;
    5. Have the duty to advocate for programs to assist problem gamblers and their families; and
    6. Demonstrate the capacity to provide programs and services for those affected by problem gambling;


    Please refer to your current copy of the Affiliates Standards, Renewal and Application Policy for complete details.

    Affiliates must complete the renewal process or request an extension by April 30th to continue membership for the next year.

    All affiliate memberships that are not renewed expire on May 31 each year.

    Affiliates that are unable to complete the process on time must request an extension or waiver in writing by April 30th.

    Requirements for renewal:
    1. Maintain all standards and requirements set forth in the Affiliate Standards Policy, and any additional requirements which may be listed in the current Affiliate New Member Application.
    2. Complete the Affiliate Membership Renewal Application and supporting documents;
    3. Provide the following to NCPG:
    ---A copy of the applicable IRS Form 990, 990-PF,999A, 990EZ, or 990-N (postcard) as submitted to the IRS by the Affiliate, covering the Affiliate’s completed tax year as of the year before the currently completed one;
    --- For example, for your renewal due April 30, 2017, you would submit your taxes from FY2015.
    ---The completed Affiliate Renewal Application, and all documentation required by the application.
    4. Make timely payment of annual dues as determined by the NCPG Board of Directors, or submit a written request for waiver from the payment of annual dues in a form stipulated by the NCPG Board of Directors.

    You may want to compose your responses first as a separate document and then copy and paste them into the online form. You will be able to save your work in the online form and return to it later but only via a link in your confirmation email.

  • Basic Information

  • Street AddressCityState CodeZIP 
  • Street AddressCityState CodeZIP 

  • Representative & Alternate

    Each Affiliate is required to have an official Representative to serve as the main conduit of information. The Representative becomes an ex officio NCPG Member and receives the same membership benefits as an Individual Plus Member. The Alternate steps in when the Representative is not available. The Alternate is required to have an NCPG membership of some type. The Representative and Alternate should plan to serve for the full Affiliate membership year (June 1 to May 31). In the event that either person changes during the year, you will need to inform NCPG in writing on the Change of Affiliate Rep & Alternate form (provided in the Affiliate Committee documents section of the website). If the Representative steps down, that person also releases their member benefits.
  • FirstLastTitleEmailPhone 
  • FirstLastTitleEmailPhone 
    The Alternate substitutes for the Representative when deemed necessary, and may vote on Affiliates Committee matters on behalf of the Affiliate in the Representative's absence. *Please note (new):the Alternate must be an NCPG member.
  • Staff

  • FirstLastTitleEmailPhone 
    Please provide the information for your organization's primary contact person.
  • Accepted file types: pdf.
    Please upload a complete list of staff names and contact information, including titles, phone numbers, and email addresses. Only pdf files allowed; 2MB max file size.
  • Alternatively, please use this field to list staff names and contact information.
    Add a new row
  • Board of Directors

  • Please attach a complete list of your Affiliate’s Board of Directors, including address, phone number and email. Only pdf files allowed; 2MB max file size.
    Accepted file types: pdf.
  • Alternatively, please use this field to list board member names and contact information. Use the + sign button to add more lines.
    Add a new row

  • Officers

    Please list your Affiliate’s current Officers, including address, phone number and email (required pursuant to Section 3.2 of the NCPG Bylaws).

  • NameAddressEmailPhone 
  • NameAddressEmailPhone 
  • NameAddressEmailPhone 
  • NameAddressEmailPhone 
  • NameAddressEmailPhone 
  • Mission and Neutrality Statements

    Please provide your mission statement.

    If your statement of neutrality on legalized gambling is not included in your mission statement, please include a separate statement to that effect.
  • If you prefer, upload a copy of your mission statement and statement of neutrality. Only pdf files allowed; 2MB max file size.
    Accepted file types: pdf.
  • Activities

  • Please provide the text of your most recent annual report or list of activities. If you include a report on Helpline services, please submit only a summary.
  • If you prefer, upload a copy of your most recent annual report of list of activities. Only pdf files allowed; 2MB max file size.
    Accepted file types: pdf.
  • Percent of Budget Allocated To:

  • For your most recent completed fiscal year only, please provide your budget allocation by percentage.
    The total of budget categories should sum to 100.

    Helpline: %

    Treatment: %

    Research: %

    Prevention: %

    Recovery: %

    Certification/Training: %

    Public Awareness: %

    Responsible Gaming: %

    Administration & Overhead: %

    Other: %

    Total (must = 100): %

  • Services

  • Helpline Services

  • Public Awareness and Prevention Services

  • Advocacy

  • Accomplishments

  • What are the top three accomplishments of your Affiliate in the last year?
    Note: 1000 characters maximum, each:
  • Assistance

    What are the top three things for which your Affiliate might want assistance from NCPG? Note: 1000 characters maximum, each: