Members

NYCPG Membership Application

Please fill out the form, print your completed form out then mail to:

NY Council on Problem Gambling
119 Washington Avenue
Albany, NY 12210

	$25 Individual Member - Full membership for any individual over 18 years of age.
	$100 Sponsor Contributor - Financial donation
	$500 Patron Contributor - Financial donation
	$1,000 Corporate Contributor - Financial donation

Name:
Agency Affiliation:
Title:
Address:
City:	State:Zip Code:
Telephone Number:	- -
FAX Number:	- -
Email Address:

Enclosed is a:	Check for $
	Money Order for $

Make all checks/money orders payable to:

NY Council on Problem Gambling
119 Washington Avenue
Albany, NY 12210
( All Donations are Tax Deductible )

The New York Council on Problem Gambling does not accept
donations, contributions, and/or grants of any kind from the gambling industry
operators or gambling equipment manufacturers.
Members will receive library privileges, discounts for specific trainings, and up-to-date problem gambling news and information.