NCPH Membership Form

Registration form without payment required, for facilitating group registrations or when someone other than the registrant is paying for membership. This is NOT your final registration; NCPH will register you formally using the information you provide here.

Main Member Information

Name(Required)

First Last

Organization or Affiliation(Required)

Please let us know how to list your affiliation, organization, or--if you are unaffiliated--how you'd like to be listed in our database (ie Consulting Historian, Independent Historian, etc.)

Email(Required)

This should be the email address of the member, which may be different than the email of the person paying for the membership.

Registration Rate(Required)

Address(Required)

This should be the address of the member, not the billing address for the membership (if different).

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Information

Student Registrants

If you're registering at the student rate, please tell us your school and advisor.

Group Registration Arrangements

Name for Payment

Who is the contact for arranging payment for this registration?

First Last

Email for Payment

What's the email of the person above?

Thank you!

NCPH will use the information provided on this form to set up your member profile. We'll work with the party indicated to arrange for payment and contact you if we have any questions.