New Affiliate Membership Application - National Council on Problem GamblingNational Council on Problem Gambling

PLEASE NOTE: Compose your responses first as a separate document and then copy and paste them into the online form.

You *should* be able to save your work in the online form and return to it later via a link from your confirmation email, not from the same URL you used to start the application. However, the web form has proven itself to be buggy and may not save; we do not as yet have an alternative platform to use.

Thank you for your interest in becoming an Affiliate of NCPG. This application is the first step to becoming an Affiliate member.

Any applicant for Affiliate membership must, at a minimum:

1) Have its principal office in its home State and maintain a telephone and email address;

2) Be legally qualified as a State non-profit entity;

3) Be legally qualified under Federal law as a non-profit entity;

4) Have a written policy statement and demonstrate that the organization is neither for nor against legalized gambling;

5) Have a Board of Directors that represents a broad cross-section of stakeholders on gambling issues;

6) Have the duty to advocate for programs to assist problem gamblers and their families;

7) Have the capacity to pay annual dues;

8) Have demonstrated the capacity to provide programs and services for those affected by problem gambling.

Applicants are requested to send a cover letter and any supporting materials to the NCPG office via this online form or by mail. The burden is on the applicant to demonstrate they, at a minimum, meet the 8 criteria listed above.

The application will be reviewed by NCPG staff, referred to the Affiliates Committee and placed on the Board of Directors meeting agenda. The Affiliates Committee will consider the application and may provide a recommendation to the Board of Directors. Then the Board will consider the application and any additional information. The Board maintains the sole authority to accept or reject an application for Affiliate Membership.

Problem gambling is an important national public health issue, and we look forward to working with you on behalf of problem gamblers and their families in your state. Please feel free to contact us with any questions or comments.

A1. Basic Information

Applicant Organization Name*

Mailing Address*

Street Address	City	State Code	ZIP

Shipping Address (if different from mailing address)

Street Address	City	State Code	ZIP

Do you have an active website?*

Yes
No

Website

Please enter your website's URL, starting with http://

Is the principal Affiliate office located in the state it represents?*

Yes
No

Does the Affiliate maintain an active business telephone?*

Yes
No

Phone number

Does the Affiliate maintain an active business email address?*

Yes
No

Email address

Is the Affiliate incorporated as a non-profit organization in the state that it represents?*

Yes
No

State Tax ID/EIN

Is the Affiliate a Federally-recognized 501(c)(3) not-for-profit organization?*

Yes
No

Federal Tax ID/EIN

A2. Affiliate 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 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 form (provided in the Affiliate Committee documents section of the website). If the Representative steps down, that person also releases their member benefits.

Affiliate Representative - Contact Information*

First	Last	Title	Email	Phone

Affiliate Alternate - Contact Information

First	Last	Title	Email	Phone

A3. Staff

Please list your Problem Gambling staff members or consistent volunteers. You may also upload a document with the list if you prefer - see below.

Use these fields to list staff names and contact information. Use the + symbol on the right to add more lines.

First	Last	Title	Email	Phone

Primary Contact

First	Last	Title	Email	Phone

Please provide the information for your organization's primary contact person.

List of staff and/or consistent volunteers.

Accepted file types: pdf, Max. file size: 2 MB.

Please upload a complete list of staff and consistent volunteers names and contact information, including titles, phone numbers, and email addresses. Only pdf files allowed; 2MB max file size.

We do not have any paid staff

A4. Board of Directors

Use these fields to list board member names and contact information. Use the + symbol on the right to add more lines.

First	Last	Title	Email	Phone

Upload Board of Directors List

Please attach a complete list of your Affiliate’s Board of Directors, including contact information: address, phone number and email. Only pdf files allowed; 2MB max file size.

Accepted file types: pdf, Max. file size: 2 MB.

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

President / Chair*

Name	Address	Email	Phone

Vice President / Vice Chair

Name	Address	Email	Phone

Secretary

Name	Address	Email	Phone

Treasurer*

Name	Address	Email	Phone

Secretary/Treasurer (combined role)

Name	Address	Email	Phone

A5. Mission and Neutrality Statements

Mission Statement

Please provide your mission statement. If your role or duty in advocating for services for problem gamblers and their families and your statement of neutrality on legalized gambling is not included in your mission statement, please include separate statements to that effect as well.

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, Max. file size: 2 MB.

A6. Activities

Annual Report or Planned Activities

Please provide the text of your most recent annual report or list of planned activities. If you include a report on Helpline services, please submit only a summary.

Upload Activities

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, Max. file size: 2 MB.

A7. Services

Please check all services you provide or plan to provide.

Helpline
Research
Recovery
Public Awareness
Treatment
Prevention
Counselor Certification/Training
Responsible Gaming

Other/comments

Please provide your budgeted allocation to activities by percentage of the whole. Use your most recently completed fiscal year, if applicable; otherwise use your planned budget.

The total of budget categories should sum to 100.
Helpline: %
Treatment: %
Research: %
Prevention: %
Recovery: %
Certification/Training: %
Public Awareness: %
Responsible Gaming: %
Administration/Overhead/Fundraising: %
Other: %
Total (must = 100): %

A8. Assistance

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

Assistance #1

Assistance #2

Assistance #3

Annual Gross Income Ranges	Dues
$500,000 and above	$5,000
$450,000 to $499,999	$4,500
$400,000 to $449,999	$4,000
$350,000 to $399,999	$3,500
$300,000 to $349,999	$3,000
$250,000 to $299,999	$2,500
$200,000 to $249,999	$2,000
$150,000 to $199,999	$1,500
$100,000 to $149,999	$1,000
$50,000 to $ 99,999	$500
$0 to $ 49,999	$100

State Affiliates

Interested in becoming a new state or regional Affiliate?

New Affiliate - Application Form

A1. Basic Information

A2. Affiliate Representative & Alternate

A3. Staff

A4. Board of Directors

A5. Mission and Neutrality Statements

A6. Activities

A7. Services

A8. Assistance

B9. Legal Forms and Information

B10. Gross Income and Dues Information

Affiliate Dues Schedule

B11. Cover Letter

B12. Finish

PROGRAMS & RESOURCES

HELP & TREATMENT

TRAINING & CERTIFICATION

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