Affiliate Membership Application

Thank you for your interest in the CCIAOR Affiliate Program.

2023 Affiliate Membership Dues: $250.00

Primary Contact First Name *

Primary Contact Last Name *

Company Name *

Company Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Website *

Are you interested in adding additional individuals to our mailing list? The cost is $50 additional per person per year. If yes, your card will be charged an additional $50 per secondary affiliate member you would like to add. *

Yes

No

List the names and emails of the additional individuals you would like to add: *

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How Did You Hear About the Affiliate Program? *

CCIAOR Website

Current Affiliate Member

CCIAOR Member

Other Other

Did anyone refer you to the Affiliate Program? If so, please list their name below:

Event & Program Sponsorships *

I am interested in sponsoring additional events/workshops. Please contact me for details.

I am not interested in sponsoring events/workshops.

Agreement & Payment

I understand that completing this application does not guarantee my Affiliate Membership and that my application must be reviewed and approved by Association staff.

If my membership as a new member is accepted, I agree to pay the 2022-2023 CCIAOR Affiliate Membership Cost of $250; plus $50 for any additional individuals listed on my application above. I understand that my annual membership dues are non-refundable.

I agree that my act of paying dues shall evidence my initial and continuing commitment to abide by the Association Bylaws and Rules and Regulations, from time to time amended, and available on the Association website.

Credit Card Number *

Expiration Date *

Signature *

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