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ACCCTEP
Association of California Community College Teacher Education Programs

"Inspiring and educating tomorrow's teachers."     

         

Membership Application

ACCCTEP Membership and Renewal Application

(COPY and PASTE THIS APPLICATION onto a blank WordDoc; complete it; email it as "Attachment" to: khenkins@mtsac.edu)

 

* = Required Field

 

Are you joining as a new member or renewing your current membership?*


*_____I am joining as a new member.
*_____I am renewing my current membership.

Which TYPE of membership you are requesting?*

 

*_____INSTITUTIONAL MEMBER (by district or by individual colleges)
$100 (two people, minimum)
$50 (each additional person)

*_____INDIVIDUAL MEMBER
$60

*_____AFFILIATE MEMBER: (not from a California community college; may be a K-12 person or from a four-year institution; will be a non-voting member)
$50

 

HOW MANY of each type are you registering today?*

 

*_____Institutional Members (2 minimum; more may be added later)

*_____Individual Member

*_____Affiliate Member

Please complete the following information for EACH member:*

*Prefix:  ___Dr.  ___Mr.  ___Mrs.  ___Ms.

*First Name:

*Last Name:

*Position/Title:

*College:

*Campus:

College/ Department Web Site :

*Address:

*City:

*State:

*Zip:

*Work Phone Number:

Fax Number:

*Email Address:

-------------------------------------------------------------------------------------------------------------

*Prefix:  ___Dr.  ___Mr.  ___Mrs.  ___Ms.

*First Name:

*Last Name:

*Position/Title:

*College:

*Campus:

College/ Department Web Site :

*Address:

*City:

*State:

*Zip:

*Work Phone Number:

Fax Number:

*Email Address:

------------------------------------------------------------------------------------------------------------

*Prefix:  ___Dr.  ___Mr.  ___Mrs.  ___Ms.

*First Name:

*Last Name:

*Position/Title:

*College:

*Campus:

*Address:

*City:

*State:

*Zip:

*Work Phone Number:

Fax Number:


*Email Address:

-------------------------------------------------------------------------------------------------------------

*Prefix:  ___Dr.  ___Mr.  ___Mrs.  ___Ms.

*First Name:

*Last Name:

*Position/Title:

*College:

*Campus:

*Address:

*City:

*State:

*Zip:

*Work Phone Number:

Fax Number:

*Email Address:

 

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Please review this form carefully. Make sure all information provided is correct.

COPY and PASTE THIS APPLICATION onto blank WordDoc; complete it; email as "Attachment" to: khenkins@mtsac.edu
Upon receipt of membership application, the Primary Member(s) will receive a confirmation.

If you have any questions, please contact: aperlstein@elcamino.edu

 

Cerritos College Foundation Tax ID # is 95-3387108

====================================================================

 

Method of Payment* (CHOOSE ONE):


*_____I am sending ACCCTEP a check.
ON THE MEMO LINE, PLEASE WRITE: “ACCCTEP Membership”
Please submit payment by check to: CERRITOS COLLEGE FOUNDATION and mail to:
Cerritos College Foundation, attn. JANICE COLE
11110 Alondra Blvd.
Norwalk, CA 90650-6298


*_____I am using a Credit Card.
Please call Janice Cole to pay over the phone (562) 860-2451, ext. 2526 or fax your credit card information (name, credit card number, expiration date) to 562-467-5041. (Please tell her payment is for ACCCTEP Membership.)
When paying by credit card, your statement will reflect a charge from Cerritos College Foundation.