NCCA Membership Application and Conference Registration

Name*

PrefixFirstLastSuffix

Membership Category (please choose carefully - this will affect further options)*

Full Membership - Applying First Time
Associate Member (CPE Student, Part-time Chaplain, Volunteer) - Applying first time
Retired (signing up first time online)
Emeritus (signing up first time online)
Executive Committee Member (signing up first time online)

By which faith group are you ordained, endorsed, commissioned, or recognized?

Board Certification

If you are Board Certified, please indicate the certifying body. Board Certification is not a requirement for membership - this information allows us to contact board certified chaplains with special requests.

Other certifying body:

Present chaplain position (check all that apply)*

If other, please indicate position:

Institution/Facility*

Preferred mailing address

Street AddressAddress Line 2CityStateZip Code

Work phone

Personal phone

Preferred email address*

Enter EmailConfirm Email

Create a password

Please create your own password so that you may be able to log into members-only areas of the website in the future. If you forget this password you will be given an option to reset your password.

Enter PasswordConfirm Password

Strength indicator

If you are a resident or student, please also provide your personal email address

Enter EmailConfirm Email

Please choose your membership category

Please Choose Your Membership Level Below*

Full Membership - $40
Associate Membership - $20
Retired/Emeritus Membership - $0

Payment Options

How are you paying?*

PLEASE READ: If you intend to submit a check with your application instead of paying online, you will receive an email confirmation to print and send with your check. Please read the information under the Total section below as well.

Credit Card or Paypal
I will send a check (IMPORTANT - see below)

Total

Please click SUBMIT in order for us to process your application. After you click Submit you will be able to pay via credit card. IF YOU ARE PAYING BY CHECK please click "CANCEL and Return to the NCCA website" on the Paypal page (it is a very small section on the lower right portion of the Paypal page) and you will be directed back to our website. You will receive an email from us within a few minutes with your application confirmation and/or payment instructions.

$0.00

North Carolina Chaplains' Association

Membership Application

Please choose your membership category

Payment Options

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