MEMBERSHIP APPLICATION/RENEWAL

NOTE: THIS APPLICATION MUST BE COMPLETED IN ITS ENTIRETY, SIGNED, DATED AND SUBMITTED WITH PAYMENT PRIOR TO CONSIDERATION.

Member Name, Credential(s): , ______

MEMBERSHIP ROSTER LISTING / MAILING INFORMATION
Business:
Department:
Address:
City, State:
Zip:
Phone: / ❏Check here if you do not want your contact information listed in the membership roster.
The membership roster is posted in the members-only password protected section of the CCRA web site. Please note that communication to members is done via email.
Fax:
E-mail:
2nd E-mail:

Please check one in each of the following sections:

Make checks payable toCCRA. Mail this form and your check to the address listed at the bottom of this application

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MEMBERSHIP CATEGORY:
Active………………………………….$ 40.00
Associate………………………………$ 30.00
Student..……………………………….$ 15.00
Sustaining…………………………….. $ 100.00
Honorary....…………………………….$ 00.00 / Distinguished Active……………….$ 15.00
Distinguished Associate…………….$ 15.00
Current President CCRA……………$ 15.00
Current Chapter Presidents……..…...$ 25.00
PAYMENT:Check: No. Dues Amount $
Include: Renewal Late Fee if paid after January 31st ……….$15.00
❏ Facility paid❏ Personal paid❏ No payment due

Instead of sending in a check you can pay by PayPal or credit card. Check the webpage for details:

LOCAL CHAPTER AFFILIATION:
❏ N-CCRA❏ C-CCRA❏ SCCRA❏ SD-CCRA
Optional donation to the Barbara Lord Scholarship Fund: ❏ $1.00 ❏ Other (specify $____)

Is your facility ACoS approved?

❏Yes ❏No ❏Planning on applying ❏Other:

CATEGORIES OF MEMBERSHIP

ACTIVE - $40 – One whose primary occupation is involved with cancer registry, a cancer data system, cancer program management, cancer research or other related fields and whose principal place of business or residence is in California. An active member shall be entitled to all membership privileges, including the right to vote, hold office or chair a committee.

ASSOCIATE - $30 – Any individual interested in the purpose of CCRA who does not qualify for active membership, such as a Certified Tumor Registrar who is no longer employed in the field or whose principal place of business or residence is outside the state of California. An associate member may not vote, hold office or chair a committee.

PAST SCCRA PRESIDENT - $25 – A person who meets the requirements of active or associate membership and has served as President of SCCRA. Chapter dues are waived.

SUSTAINING - $100 – Any organization or institution interested in the purpose of the Association. A sustaining member may not vote, hold office or serve on a committee. The organization or institution may send a maximum of two people per meeting at the member rate.

STUDENT - $15 – A person enrolled in an allied health care curriculum and interested in the purpose and principles of CCRA and who does not meet the qualifications of active membership. The student may not vote, hold office or chair a committee. An individual shall be eligible for this classification of membership for no more than one consecutive three-year period.

HONORARY - $0 – A person who is elected to this category by the CCRA membership. An honorary member is exempt from dues, and may hold no other class of membership.

DISTINGUISHED ACTIVE - $15 – A Distinguished Active Members shall retain the same privileges as Active Members without payment of the CCRA portion of dues. Component chapter dues are still required.

DISTINGUISHED ASSOCIATE - $15 – A Distinguished Associate Member shall retain the same privileges as Associate Members without payment of the CCRA portion of dues. Component chapter dues are still required.

CURRENT CCRA PRESIDENT - $15 – CCRA portion of the dues are waived. Component chapter dues are still required.

CURRENT CHAPTER PRESIDENT - $25 – Component chapter dues are waived. CCRA portion of the dues are still required.

CCRA Membership Chair c/o Wendy Lynch,

Cancer Registry, USC Norris Cancer Hospital, 1441 Eastlake Ave., Los Angeles, CA 90033

Office:(323) 865-0493FAX: (323) 865-5515  Email: