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