NEPCSA Associate Application

Associate Member Application

Company

Website

Street

City * State * Zip *

Phone

Contact #1 Name

Title #1 Email #1

Contact #2 Name

Title #2 Email #2

Product or Service -- Please check all that apply.

Administrative Services	Admissions	Advertising
Assessment	Bookstores	Campus Services
Certification	Certified Public Accountants	Collection Services
Compliance & Ethics	Consulting	Default Management
Education Management	Educational Training Materials	e-Learning / Distance Education
Employee Assessment	Employment	Financial Aid
Furniture	Information Technology	Insurance
Investment Banking	Investment Management	Legal Service
Library Service	Management Search	Marketing
Media	Medical Services	Mergers & Acquisitions
Private Equity	Promotion and Recognition Items	Real Estate Services
Receivables	Recruitment	Research
Retention	Software	Student Housing/ Campus Housing
Testing/Tools/Equipment	Training Providers	Tuition Financing

If other please list.

Please provide a brief description about your company and its products or service.

Membership Dues = $400 (The NEPCSA fiscal year runs from July 1st - June 30th.)

Total

Account # Billing Zip Code

Payment Type

AMEX Master Card Visa Exp. Mo. Exp. Yr. Security #

First Name

Last Name Email

NEPCSA

11 Robert Toner Blvd., # 234 | North Attleboro, MA 02763 Phone: (508) 695-3919