2. 
3. Affiliate Membership Application

   2022 Calendar Year Membership Complete and then Submit and Print

5. Membership Level
   -- Select One --Platinum $2,000Gold $1,500Silver $1,250Basic $1,000
7. Organization Name
8. Contact Email Address
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Fax Number
19. Organization Web Page
20. Organization Facebook
22. Contact First Name
23. Contact Last Name
24. Role/Title
25. Contact Telephone
27. Notes
29. Questions -- Contact
    Ernie Holling, Executive.Director@ccato.org 610-827-2241
31. Payment - Credit Card
    Credit Card Payment
33. Payment -- Check
    Send to: CCATO Affiliate Membership, Post Office Box 219, New London, PA 19360
35. Thank You for your support of CCATO's mission and programs.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field