C.E.S.A. COASTAL CHAPTER
MEMBERSHIP FORM
January - December 2002

This form is for new membership application or membership renewal.

CHECK ONE: q New Membership q Membership Renewal

 

Name of organization/affiliation:___________________________________________________

Name of Member(s) (You may list up to four names for Group Memberships):
Please list all names to establish new membership and/or confirm membership renewal

 

1.________________________ Title_______________________  e-mail______________________

2.________________________ Title_______________________  e-mail______________________

3.________________________ Title_______________________  e-mail______________________

4.________________________ Title_______________________  e-mail______________________

 

Mailing Address:_________________________________________________________________

City/State/Zip:____________________________________________________________________

Phone:________________________________ Fax:____________________________________

 

ANNUAL DUES:   q $100.00 - Group (Two to Four Persons)        q $50.00 - Individual

MAKE CHECKS PAYABLE TO CESA COASTAL CHAPTER

MAIL TO:

Cherel Sampson
City of Sunnyvale DPS - Emergency Preparedness Unit
700 All American Way
Sunnyvale, CA 94086


CESA Coastal Chapter includes the following counties:

ALAMEDA LAKE NAPA SANTA CLARA
CONTRA COSTA MARIN SAN BENITO SANTA CRUZ
DEL NORTE MENDOCINO SAN FRANCISCO SOLANO
HUMBOLDT MONTEREY SAN MATEO SONOMA

(( If you have questions/changes related to your membership, please contact Cherel Sampson, Coastal Chapter Membership Chairperson at:
E-mail address:            csampson@ci.sunyvale.ca.us
Phone:                          408-730-7198