LEGAL AID GROUP MEMBERSHIP ENROLLMENT FORM

LEGAL AID GROUP MEMBERSHIP ENROLLMENT FORM
Membership Year 2015-2016
PLEASE HAVE YOUR EXECUTIVE DIRECTOR OR PRESIDENT SIGN AND SUBMIT THE MEMBERSHIP PLEDGE BELOW.
PLEASE VERIFY THAT PROFILE INFORMATION AND EACH ENROLEEE’S INFORMATION IS ACCURATE AND COMPLETE.
For more information on the benefits of NACA membership, visit www.consumeradvocates.org/join.
GROUP MEMBERS MUST USE OFFICIAL ORGANIZATION EMAIL ADDRESS TO RECEIVE LISTSERV BENEFITS
OFFICIAL EMAIL
FULL NAME OF ORGANIZATION:
1
FIRST NAME
LAST NAME
TITLE
2
FIRST NAME
LAST NAME
TITLE
3
FIRST NAME
LAST NAME
TITLE
4
FIRST NAME
LAST NAME
TITLE
5
FIRST NAME
LAST NAME
TITLE
■ EIN/ Tax ID
■ Year Est.
■
# of Employees
■
DIRECT PHONE
# of Locations
NACA MEMBERSHIP PLEDGE
By my signature below I pledge:
1.
2.
3.
4.
I am committed to advancing the cause of just treatment for and ethical representation of consumers.
I will not, so long as I am a NACA member, perform services for any business or commercial client (as
defined in the application for membership) on a matter where that client's interests are adverse to the
interests of a consumer or consumers. I also do not have any present intention or expectation of
doing so in the future.
If there are any material changes in work done by me, my firm or MY employer which could be adverse to
the interests of consumers, I will immediately provide NACA with a full written explanation.
I will abide by all listserv rules relating to confidentiality of communications on any email listserv administered
by NACA or the National Consumer Law Center. This portion of the pledge shall remain binding on me
permanently, even if I resign from NACA or my membership is suspended or revoked.
President/Executive Director Enrollee Pledge Signature:
Date:
❏ PAYMENT IS ENCLOSED FOR GROUP RATE OF $425
Mail application to:
National Association of Consumer Advocates | 1215 17th Street, NW, 5th Floor | Washington DC 20036 | TEL: (202) 452-1989 | FAX: (202) 452-0099
COMPLETE PRIMARY CONTACT/ BILLING INFORMATION BELOW
❑ A CHECK IS ENCLOSED ❑ PAY BY MC/VISA, AMEX, OR DISCOVER
FIRST NAME/ LAST NAME:
TITLE:
ORGANIZATION:
STREET ADDRESS:
CITY/ STATE/ ZIP:
EXP: (
CREDIT CARD NUMBER:
PHONE:
FAX:
BILLING EMAIL:
WEBSITE:
/
)