National Association for Children of Alcoholics

AFFILIATE APPLICATION

NAME OF AFFILIATE__________________________________________________________

INCORPORATED NAME _______________________________________________________

(IF DIFFERENT)

ADDRESS____________________________________________________________________

______________________________________________________________________________

PHONE________________________________FAX________________________________

E-Mail_________________________________Web___________________________________

CONTACT PERSON____________________________________________________________

HOW AFFILIATION WILL STRENGTHEN YOUR ORGANIZATION=S MISSION:

______________________________________________________________________________

Please include the following with your application:

1) Articles of Incorporation

2) Evidence of 501(c)3 IRS status or pending status

3) One of the following:

a) $250 Annual Affiliate fee

b) $100 Pre-Affiliate fee, if incorporation and IRS status pending

4) Organization=s mission statement and description of programs and services

Name_________________________________Title____________________________________

Signature______________________________Date____________________________________

11426 Rockville Pike, Suite 100 Rockville, Maryland 20852

1-888-55-4COAS(2627) FAX(301)468-0987