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National Council on Problem Gambling Affiliate Membership Renewal - 2018
For current affiliates only. 
Affiliate Members are non-profit organizations that support and implement the purpose, mission and goals of the NCPG, and serve as the official representative of NCPG in their respective state(s). Affiliate Membership is a status of Membership separate from and different than either Individual or Organizational Membership in the National Council on Problem Gambling (NCPG).  

The goal of the NCPG Affiliates Membership program is to have an active and effective Affiliate chapter in each state, providing meaningful programs and services to people affected by problem gambling. As representatives of  the national association, all Affiliates are required to meet or exceed the following standards:  
 
AFFILIATE MEMBERSHIP STANDARDS
At all times during its membership, an Affiliate Member is expected to:
1. Have a principal office in the state it represents and maintain a working phone number and email address;
2. Be legally qualified as a Federal 501(c)(3) non-profit entity and meet all required city, state and federal business and nonprofit requirements, as applicable;
3. Have a Board of Directors that represents a broad cross-section of stakeholders on gambling issues and convenes at least one time per year;
4. Have a written policy statement that the organization is neither for nor against legalized gambling; 
5. Have the duty to advocate for programs to assist anyone affected by problem gambling; and
6. Demonstrate the capacity to provide programs and services for those affected by problem gambling. 
 
AFFILIATE ANNUAL MEMBERSHIP RENEWAL
Please refer to your current copy of the Affiliates Standards, Renewal and Application Policy for complete details. 
--Affiliates must complete the renewal process. Any affiliate memberships that are not renewed expire on May 31 each year. 
--In extraordinary circumstances, affiliates may request an extension of time to complete the renewal documents or pay dues; or a reduction of dues. This must be done in writing by April 30. Even if a dues reduction is granted, affiliates must still submit your renewal form and documents.
 
 
 
Requirements for Renewal:
1. Maintain all standards and requirements set forth in the Affiliate Standards Policy, and any additional requirements that are listed in the current Affiliate New Member Application here:
2. Make timely payment of annual dues as determined by the NCPG Board of Directors, or submit a formal written request for reduction of annual dues to the NCPG Board of Directors.  
 
3. Provide the following to NCPG by April 30:
---The completed Affiliate Renewal Application form and all documentation required by the application.
---A copy of the applicable IRS Form 990, 990-PF,999A, 990EZ, or 990-N (postcard) as submitted to the IRS by the Affiliate, covering the Affiliate’s tax year completed as of two years earlier (for example, for your renewal due April 30, 2018, you would submit your taxes from your FY2016, which for most affiliates would be the fiscal year ending 6/30/16 or 12/31/16).  
 
4. Please note: you must include the 990 from your 2016 fiscal year.   
 
You should compose your responses first as a separate document and then copy and paste them into the online form. You will be able to save your work in the online form and return to it later via a link in your confirmation email. Sometimes this is not 100% reliable depending on which browser and what version of it you are using - in particular, we recommend that you do NOT use Internet Explorer. But if you compile your responses separately first, you will not lose your work.  
 
If necessary, you can also use a Word document version of the form and return it by email (preferred), fax or mail.
 
 
 
REQUIRED DOCUMENTS
     Board list, detailing officers and contact info
     Staff list, including contact info (if applicable)
     IRS 501(c)(3) letter
     Mission statement and statement of neutrality
     Budget allocation to activities 
     990 or applicable version of it  (from your FY2016)
Optional documents:
     Annual report or list of planned activities
 
 
 
A1. Basic Information
 
 
 
Please use current, updated information for these fields.
 
 
 
* Organization Name
   
 
 
Mailing Address
* Address Line 1 : 
   Address Line 2 : 
* City : 
    * State     * Zipcode
 
 
Shipping Address (if different from mailing address)
Address Line 1 : 
Address Line 2 : 
City : 
    State     Zipcode
 
 
*Directory Information (information given on NCPG website and elsewhere as a help resource)
Address Line 1 : 
Address Line 2 : 
City : 
    State     Zipcode
Phone : 
Email Address : 
 
 
 
* Website (type in starting with http:// before your website)
   
 
 
 
* Office Phone Number
   
 
 
 
* Does the Affiliate maintain an active business email address?
 
Yes
 
No
 
 
 
* Affiliate's Business Email Address
   
 
 
 
* Please confirm your information as displayed on NCPG's website

One of your benefits as an Affiliate is having your organization's contact information shared on our About Us and Help By State pages. Please visit BOTH pages now and review your section.

https://www.ncpgambling.org/about-us/state-affiliates/
https://www.ncpgambling.org/help-treatment/help-by-state/

Are there any changes to be made to your information?           
 
Yes
 
No
 
 
 
If yes, please tell us what the changes are.
   
 
 
 
* Is the principal Affiliate office located in the state that it represents?
 
Yes
 
No
 
 
 
* Is the Affiliate a Federally-recognized 501(c)(3) not-for-profit organization?
 
Yes
 
No
 
 
 
* Your federal Tax ID/EIN
   
 
 
 
* Is the Affiliate incorporated as a not-for-profit organization in the state that it represents?
 
Yes
 
No
 
 
 
Your State Tax ID/EIN (if different from your Federal EIN)
   
 
 
 
A2. Affiliate Representative & Alternate
 
 
 
Each Affiliate is required to have an official Representative to serve as the main conduit of information and communication. The Representative becomes an ex officio Member of NCPG and receives the same membership benefits as an Individual Plus Member except that these benefits end when the Representative steps down.

Each Affiliate should have an Alternate Representative. The Alternate Representative 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 upon request). If the Representative steps down, that person also releases their member benefits.

The Alternate substitutes for the Representative when deemed necessary, and may vote on Affiliates Committee matters on behalf of the Affiliate in the Representative's absence.

*Please note: As of December 2016, the Alternate must be an NCPG member.
 
 
Affiliate Representative - Contact Information
* First Name : 
* Last Name : 
* Phone (xxx-xxx-xxxx)
 : 
* Email Address : 
 
 
Affiliate Alternate - Contact Information
* First Name : 
* Last Name : 
* Phone (xxx-xxx-xxxx) : 
* Email Address
 : 
 
 
 
Alternate's NCPG Membership ID# if you know it
   
 
 
 
A3. Staff
 
 
 
* Do you have any paid staff?
 
Yes
 
No
 
 
 
If yes, please upload a complete list of staff names and contact information, including titles, phone numbers, and email addresses (on the next page).
 
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