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.

*Official Name of Affiliate:

*Your name:

*Your email address:

NCTM REPRESENTATIVE: (Must be a member of NCTM)

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

PRESIDENT: (Must be a member of NCTM)

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

TREASURER:

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

EDITOR (NEWSLETTER):

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

EDITOR (JOURNAL):

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

COMMUNITY RELATIONS:

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

EXECUTIVE SECRETARY:

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

PRESIDENT ELECT:

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

MEMBERSHIP CHAIR:

Term Expires:
(month/year)

NCTM Membership Number:

Expiration Date:
(month/year)

Home Address:

City:

State/Province:

Zip/Postal Code:

E-mail:

Work Phone:

Fax:

Home Phone:

Title of Newsletter:

Title of Journal:

Website: