Organizational Member Application Form
Membership Processor 4.0
ORGANIZATIONAL INFORMATION
Organization Name
Address
City
State/Province
Zip/Postal Code
Country
Type of Organization
Please check all that apply
Private Practice 
Private, not for profit non-religious agency 
School (K ­12) 
Private, not for profit religious agency 
Private, for profit agency 
College/University
Public, governmental agency 
Other 
Please Specify
Primary Field(s)
of Service
Please check all that apply
Aging 
Family Service 
Substance abuse
Child Welfare 
Health/hospital 
Legal services
Church social ministry 
Housing 
Military
Corrections/Justice 
Income maintenance 
Public welfare/Government
Developmental disabilities 
Industry/Business/Labor 
Youth services
Education for social work 
Mental Health 
Other  Please Specify
Budget Size Over $500,000 
$100,000 - $249,999 
$250,000 - $500,000 
Under $100,000
No Budget
DESIGNEE INFORMATION
(Person Who Will Receive NACSW Materials and Exercise Membership Rights on Behalf of the Organization)
Contact Person's Name
Position Title
Phone
Primary Email Address
Fax Number
Website Address/URL 
Special Interests Is the organization's designated person interested in participating in a special emphasis area (for example, individual counseling, substance abuse specialization,  church social work, etc.) sponsored by NACSW? If so, please indicate area/specialty: 
NO  YES 
Is the organization's designated person willing to be a contact/coordinator of special emphasis area (for example, individual counseling, substance abuse specialization, church social work, etc.)? If so, please indicate area/specialty: 
NO  YES 
Current Professional Memberships NACCFA
Christian Management Association 
Other(s) - please list

Referral Information How Did You First Hear of NACSW? Please Specify Who

Please Specify
First Name
Last Name
Writing/Presenting Is anyone in your organization interested in writing for NACSW's newsletter (Catalyst) or journal (Social Work and Christianity) - including sharing with other NACSW members about the work of your organization? 
NO  YES 
 Is anyone in your organization interested in presenting at an NACSW conference or convention - including sharing with other NACSW members about the work of your organization? 
NO  YES 
Is your organization interested in representing NACSW at events sponsored by your organization and/or other professional activities in which your organization participates? 
NO  YES 
Group/Chapter Activity Are members in your organization interested in participating in local group or chapter activities sponsored by NACSW? 
NO  YES 
Is your designated person willing to be a local contact/leader of a local group or chapter in your area? 
NO  YES 
Membership Certificate Information

Please indicate below exactly how you would like your organization's name to appear on your free membership certificate (for example, Christian Family Services, Inc.)