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 the form, , (don’t forget to sign it), then mail it with check payable to CSCA to:

Robert Foucrault, CSCA EXECUTIVE SECRETARY, 211 Bradbury Lane, Redwood City, CA 94061