NCBA CLUSA - Contact Designation Form

Thank you for your membership with NCBA CLUSA. In an effort to direct our communications to the appropriate contact within your organization, we would like you to designate a few members within your organization as specific contacts for items such as billing, board voting etc. Please fill in the below form and submit in order to update our records.

Name*

First NameLast Name

E-mail*

Co-op/Org Name*

Co-op Industry Org Type*

Board Elections/Voting Contact

This employee will serve as the designated contact to vote in board elections (and other governance-related matters) on behalf of the co-op or organization.

Voting Contact Name*

First NameLast Name

Voting Contact E-mail*

example@example.com

Job Title

Invoice Billing Contact(s)

You are welcome to confirm and/or update the invoice contacts for your co-op or or organization.

Billing Contact (s)

	First Name	Last Name	Job Title	Email	Notes
#1
#2
#3
#4

Is your address U.S. Domestic?*

Within the United States of America (USA) or U.S. TerritoriesOutside of the United States of America (USA)

Home/Residential or Work*

Residential AddressWork/Business Address

U.S. Domestic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

International Address

(For document upload if necessary)

Browse Files

Allowable file types = pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi. Max size = 10MB

General Comments or Recommendations

Designated Account Contacts