ON-LINE MEMBERSHIP FORM

Complete the membership form below, and click “Confirm & Send”.?

After completing and sending the membership form, you will be returned to this page automatically. At that time, please make your payment of the annual CCCUN membership dues here. Payments are made via Paypal. You do not need a Paypal account to pay. Paypal?accepts?Credit and Debit cards.?

Click the button above, labeled "Membership Dues” to Pay?Online.

After you submit your payment you will receive an email?confirmation?from Paypal. Thank You for your support!

Subject:

Email:

Re-Enter Email:

Title:

Title (Other):

First Name:

Middle Initial:

Last Name:

Degrees:

Name of Organization/Affiliation:

Position:

Mailing Address:

Address
Home Business
City:

State:

Zip Code:

Province & Country (If not U.S.A.):

Telephone:
Work Home
Telephone Number:

Mobile Phone:

Fax Number:

Your major areas of interest:

Possible resources or skills that you might bring to the work of CCCUN:

Role you would like to play in the CCCUN:

Membership Dues:
Regular Membership $50 Full time Student (Undergrad/Grad) $10
Donations are always welcome. Please indicate amount below:

Additional Message:

Click the button labeled “Confirm & Send” above.

CCCUN

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ON-LINE MEMBERSHIP FORM