CSCA Membership Application

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:
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.
Date:

Name: 

Title: 
Sign: ______________________________________
Fill out form (don’t forget to sign it), then PRINT THIS FORM and mail with check payable to CSCA to:

Gary D. Tindel, Executive Secretary CSCA, 1947 Heidi Way, Yuba City, CA 95993-1427