The Council on Compulsive
Gambling of New Jersey, Inc.
(Contributions to
CCGNJ, Inc. are tax-deductible)
Title (If applicable):___________________________________________________________
Organization (if applicable):____________________________________________________
Address:___________________________ City:______________ State:_____
Zip:_______
Phone: (
)_________________________________________________________________
E-Mail Address: ______________________________________________________________
The above address
is _____ home
_____ business
I wish to be part
of the Council’s continuing efforts to help adults and adolescents in New Jersey
who are affected by gambling. Enclosed
please find my contribution for membership:
Individual Membership:
____Associate Member:
$25.00
____Contributing Member: $100.00
____ Other Amount: $___________
____My company will
match this contribution
____Charge to my account Mastercard____
Visa_____
Account # ____________________________
Expiration Date________________________
Signature _____________________________