California Council of Cultural Centers in Higher Education

CaCCCHE MEMBERSHIP APPLICATION

APPLICANT INFORMATION (*required fields)

First Name:

Last Name:

Title:

Department:

Institution/Campus:

E-mail:

Address:

City:

State:

Zip:

Phone:

Fax:

Website:

(ie: http://www.any.com)

MEMBERSHIP LEVEL

	$75.00: Regular Membership
	$50.00: Associate / Alumni Membership
	$50.00: Graduate Student Membership
	$0.00: Undergraduate Student Membership
	$300.00: Institutional Membership

Please make check payable to CaCCCHE.
CaCCCHE Tax ID#: 94-3353763

Send registration and check to:
Victor Flores
Office of Minority Affairs and Diversity
Ethnic Cultural Center/Theatre
3931 Brooklyn Avenue NE - Box 355650
Seattle, WA 98105

(206) 616-8632
vflores@u.washington.edu

COMMITTEE INFORMATION

I am interested in becoming involved with the following standing committees:

Advocacy Development Networking