NCBA CLUSA - Contact Designation Form

Designated Account Contacts
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 Name Last 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 Name Last 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)

Is your address U.S. Domestic? *

Within the United States of America (USA) or U.S. Territories Outside of the United States of America (USA)
Home/Residential or Work *

Residential Address Work/Business Address
U.S. Domestic Address

Street Address

Street Address Line 2

City State / 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 Cancel of
General Comments or Recommendations
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Designated Account Contacts