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.



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