NESA Affiliate Organization Application Form

First Name *

Last Name *

Job Title *

Email *

First Name

Last Name

Job Title

Email

Organization *

Organization Name.

Organization Primary Email *

Organization Website *

Organization Profile *

A brief paragraph describing your organization (to be included in your organization's listing in the NESA Membership Directory and NESA NEWS welcome feature.

Organization Logo

To include your organization's logo on the Our Supporters page of the NESA website following acceptance, please upload it as a transparent-background PNG file, minimum size: 400px. 

20MB max

Address Line 1 *

Address Line 2

City *

State/Province

Postal Code *

Country *

Enter required value United States Canada Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Congo Democratic Republic of Cook Islands Costa Rica Coted Ivoire Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island and Mc Donald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isleof Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea Democratic Peoples Republic Korea Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands British Virgin Islands US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Sark

Please select your preferred Affiliate Organization Benefits Package: *

NESA offers two tiers of Affiliate Organization Benefits: a Standard Package, and a Premium Package. Please see this table for a comparison of benefits offered. 

Note: Annual Dues indicated below are applicable for the current NESA Membership Year, which runs from July 1, 2023 to June 30, 2024.

Enter required value NESA Affiliate Organization Standard Package (2023-2024 Annual Dues: $1,575) NESA Affiliate Organization Premium Package (2023-2024 Annual Dues: $2,360)

How did you hear about NESA? *

Comments

Please let us know if there is anything not covered by this form.

I confirm that the information given in this form is true, complete and accurate​ *

Electronic Signature of Head of Organization (or representative) *

Date *