The Council on Compulsive Gambling of New Jersey, Inc.

3635 Quakerbridge Road

Hamilton, NJ  08619

(609) 588-5515   phone

(609) 588-5665   fax

www.800gambler.org

Corporate Membership Application

(All donations to CCGNJ, Inc. are tax-deductible)

Name: _____________________________________________________________________

Title: ______________________________________________________________________

Organization: _______________________________________________________________

Address:___________________________________________________________________

City: _______________________________  State:  ___________  Zip: _________________

Telephone: _____________________________ E-mail: _____________________________

Our organization wishes to be part of the Council’s continuing efforts to help New Jersey residents who are adversely affected by gambling.  Enclosed please find our membership donation:

______  Less than 100 employees:                                                       $1,000.00

______ 100—749 employees:                                                                 $2,500.00

______  750—1,000 employees:                                                             $5,000.00

______  More than 1,000 employees:                                                    $7,500.00

______  Leadership and Commitment Sponsorship:                    $10,000.00

                        ______  In addition to the above membership donation, our organization would like to

               make an additional one-time donation of $__________________.