Type of Membership (please circle one): Active Associate Lifetime Institutional
Name _________________________________________________________
School ________________________________________________________
Department ____________________________________________________
School Address _________________________________________________
City ____________________________ State ______ Zipcode ___________
School Telephone Number ______ ______ - ________ EXT ________
Home Address __________________________________________________
City ____________________________ State ______ Zipcode ___________
Home Telephone Number ______ ______ - ________
Mailing Preference ____ HOME ____ SCHOOL
E-MAIL ADDRESS ___________________________________________________________
Please note that your email address may be shared with other members of this consortium.
Please make check payable to:
Community College Computer Consortium
[ ] I enclose my personal check in the amount of $ ______________
[ ] My school will forward a check in the amount of $ ____________
[ ] This is a renewal
Signature: __________________________________ Date _______________
Please mail this form with your check to:
Dues Schedule (July 1st to June 30th)