This form may be used to submit information for up to nine Affiliate officers. The Affiliate's NCTM representative and president should be a current member of NCTM.
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*Official Name of Affiliate:
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*Your name:
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*Your email address:
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NCTM REPRESENTATIVE:(Must be a member of NCTM)
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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PRESIDENT: (Must be a member of NCTM)
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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HomePhone:
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TREASURER:
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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EDITOR(NEWSLETTER):
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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EDITOR (JOURNAL)
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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COMMUNITY RELATIONS:
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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EXECUTIVE SECRETARY:
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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PRESIDENT ELECT:
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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MEMBERSHIP CHAIR:
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Term Expires:
(month/year)
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NCTM Membership Number:
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Expiration Date:
(month/year)
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Home Address:
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City:
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State/Province:
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Zip/Postal Code:
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E-mail:
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Work Phone:
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Fax:
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Home Phone:
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Title of Newsletter:
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Title of Journal:
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Website:
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