Affiliate Application

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Organization(Required)

DBA Name

Please note if your organization is doing business under a different name.

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Organization

Contact Name & Title(Required)

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Contact Name & Title

Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address

If different than the street address.

Street Address Address Line 2 City State ZIP Code

Email(Required)

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Phone(Required)

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Phone

Website

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Website

Legal Status(Required)

501(c)3

501(c)4

Chapter/Hub of Another Group

University/College

Unincorporated Community Group

Other

Federal Tax ID Number(Required)

Please include your group's federal tax ID number or the tax ID number of the organization of which your group is a chapter/hub. Numbers can be looked up in this directory: https://www.irs.gov/charities-non-profits/tax-exempt-organization-search

NC Charitable Solicitation License Number(Required)

Please include your group's solicitation license number with the NC Secretary of State or the license number of the organization of which your group is a chapter/hub. If you can't find a license number, type n/a. Numbers can be looked up in this directory: https://www.sosnc.gov/online_services/search/by_title/_charities

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Legal Status (Please check all that apply.)

501(c)3

501(c)4

University/College

Unincorporated Community Group

Chapter/Hub of Another Group

Other

Organizational Mission(Required)

Annual Operating Expenses(Required)

Numbers only, please (if none, write 0).

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Annual Operating Expenses

Numbers only, please (if none, write 0).

Number of Members

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Number of Members

Number of Paid Staff(Required)

Numbers only, please (if none, write 0).

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Number of Paid Staff

Numbers only, please (if none, write 0).

Year Established

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Year Established

Primary services offered to members/constituents (if applicable)

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Primary services offered to members/constituents (if applicable)

Describe one or two recent initiatives, campaigns, or major activities(Required)

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Describe one or two recent initiatives, campaigns, or major activities

Describe the environmental and community issues more important to your organization(Required)

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Describe the environmental and community issues more important to your organization

Please list the names of your organization's board of directors or advisory board(Required)

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Please list the names of your organization's board of directors or advisory board

How did you hear about NC Conservation Network?(Required)

Please select all that apply.

Our website

Contacted by us

Another organization

Other

What services are you most interested in receiving?(Required)

Please select all that apply.

News Digest

Weekly Alert

Legislative Update

Website Postings (jobs & events)

Skills Training

Coalition Work

Graphic Design Work

Other

This application has been approved by the organization's Executive Director or Board President (initial).(Required)

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