Membership Form
Yes, I would like to become an NCAP member!
___ I am a new member
___ I would like to renew my membership
___ I would like to make a donation. (I am not joining at this time)

Name _______________________________________________________________

Address ____________________________________________________________

City_________________________________   State/Province __________   Zip __________

Phone: Home (_____) __________________      Work (____) ___________________

E-mail: _____________________________________________________________
E-mail is an effective and economical way for us to keep you up-to-date.

NCAP occasionally exchanges its mailing list with other organizations involved in issues you may find of interest. If you
DO NOT want your name exchanged, please check here: ___

___ $25 Basic ___ $50 Associate ___ $75 Advocate ___ $100 Sustainer

___ $500 Benefactor ___ $1,000 Toxic Avenger ___ $15 Limited Income ___ Other $_________

My employer, _____________________________, will match my gift.
Please mail us a completed Employee Gift Matching form, which you can obtain through your company's contributions or human resources office.

Method of Payment

___ Check         ___ Visa         ___ Mastercard        

Credit card number ________________________________    Expires (mm/yy)____________

Signature ______________________________________________ Date _____________

Please return this form by mail to: NCAP P.O. Box 1393 Eugene OR 97440-1393

Forms with credit card payments may also be faxed to: FAX (541) 344-6923

Thank you for your support!

If you wish to discuss specific arrangements for a charitable gift, please contact Stacey Janssen, Development Director, at (541) 344-5044 ext. 23, or by email at sjanssen(AT)pesticide.org.

The Northwest Coalition for Alternatives to Pesticides is a non-profit charitable organization as determined by Section 501(c)3 of the Internal Revenue Service, tax ID# 93-0715778. Your gift to NCAP is tax-deductible to the fullest extent permitted by law.  For specific tax information regarding your charitable giving, please consult your personal tax advisor.