CHINESE CULTURAL ASSOCIATION MEMBERSHIP APPLICATION

1. Select the type of membership:

Check One Membership Category Cost

Family Membership Membership for everyone living in the household $30.00

Couple Membership Husband and Wife $25.00
Single Membership Individual membership $20.00
Senior Membership Over 60 years of age $10.00
Student Membership Must be a full-time student (high-school or college) FREE

MEMBERSHIP FEE FOR CALENDAR YEAR 2010

2. List Primary Member:

Last Name_____________________________________ First Name _________________________________ Middle Initial ______

Street Address______________________________________________________________________________________________

City _____________________ State/Province __________________ZIP/Postal Code _________ Country_____________________

Home Phone ______________________ Cell____________________ E-mail Address ____________________________________

(For CCA use only. Not to be released to non-CCA parties.)

Work Phone ______________________ Extension __________ Fax Number____________________________________________

3. List additional members: All persons living under one household are eligible and included in the Family Membership
at no additional charge. .

Last Name First Name Age Male/Female Interests

4. Volunteer (check or write which categories you are interested in)

Cultural/Educational _____________ Newsletter _______________ Membership ____________

Fundraising ____________________ Sports __________________ Social/Ent. ______________
Seniors Games Day _____________ Youth (Teen/College ______)_____________
Childrens Events _______________ Professional _______________ Other __________________
Volunteers Name _________________________ Telephone ________________ E-Mail _______________

5. Make payment
Total from Section 1 $ ______________
Check or Money Order Only - Make payable to the Chinese Cultural Association, Inc. and mail to:
Chinese Cultural Association, Inc. ~ PO Box 165920 ~ Miami, FL 33116
Chinese Cultural Association, Inc. ~ PO Box 165920 ~ Miami, FL 33116 ~