Please accept this application along with my annual dues as my request for membership in the CSCA.  
 Type of Membership you are applying for: (Check one)

Principal ($300)

Active ($40)

Associate ($40)

Applicant's Name: 

Address: 

City:      State:      Zip:

CA County:      (If Other):      Phone: 

Your Title:      E-Mail Address: 

Type of Vendor (if applicable): 

Applicant's Signature: ____________________________________________

Certification
(Required ONLY if applying for Active Membership)

As the Coroner or Medical Examiner of County in the State of California, I hereby certify the above applicant meets the requirements for Active Membership in the California State Coroners' Association.

Name: 

Sign: ______________________________________

Title:      

Fill out form (don't forget to sign it), PRINT it and mail with check payable to CSCA to:
Scotty Hill, Executive Secretary CSCA, 5925 Maybrook Circle, Riverside, CA 92506-4549