PAYMENT REMITTANCE FORM Agency Information Fiscal Agent Information (if applicable) Agency Name: Agent Name: Address: Mailing Address: City: State: City: State: Zip Code: Zip Code: __________________________________________________________________________ Type of Membership: New Existing Please select the level of membership your organization currently holds: Accredited Associate/Developing Affiliate Satellite Support Non-member __________________________________________________________________________ Reason for Payment Application Fee (Please list the level of membership your organization is applying for): $ Annual Membership Dues (Please list the level of membership for which the dues are for): $ $ NCAtrak Initial Fee $ NCAtrak Annual Subscription $ OMS Subscription for non-members TOTAL of LINES 1-5 $ (Total) __________________________________________________________________________ PAYMENT INFORMATION Choose one: Credit Card Payment: If you wish to pay by credit card, please follow the link to the payment portal at: . If you need additional information regarding this payment, please contact our Accounting department at . Check Payment: Check #: Check Amount: $
PAYMENT REMITTANCE FORM Agency Information Fiscal Agent Information (if applicable) Agency Name: Agent Name: Address: Mailing Address: City: State: City: State: Zip Code: Zip Code: __________________________________________________________________________ Type of Membership: New Existing Please select the level of membership your organization currently holds: Accredited Associate/Developing Affiliate Satellite Support Non-member __________________________________________________________________________ Reason for Payment Application Fee (Please list the level of membership your organization is applying for): $ Annual Membership Dues (Please list the level of membership for which the dues are for): $ NCAtrak Initial Fee $ NCAtrak Annual Subscription $ OMS Subscription for non-members $ TOTAL of LINES 1-5 $ (Total) __________________________________________________________________________ PAYMENT INFORMATION Choose one: Credit Card Payment: If you wish to pay by credit card, please follow the link to the payment portal at: . If you need additional information regarding this payment, please contact our Accounting department at . Check Payment: Check #: Check Amount: $
Affiliate-Members-Application-2016.docx