Affiliate Membership Application

Thank you for your interest in the CCIAOR Affiliate Program.

Annual Affiliate Membership Dues are $250 for the year (January - December). Sign up now, and your membership will be valid for the remainder of 2024 and all of 2025.

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? *

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.

Once you sign up for the affiliate program, please forward your logo to ppry@cciaor.com. Your logo will be used for future marketing purposes (i.e., website listing, member E-News and more).

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 $250 that will be valid for the remainder of 2024 and all of 2025; 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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