Print this application and then send completed application to:
Esther Onaga
2658 Roseland Avenue
East Lansing, MI 48823
Please make checks payable to:
The Coalition for Community Living
Membership Application
| Name: | |
| Address: | |
| City, State, Zip: | |
| Country: | |
| Organization Affiliation: | |
| Phone (Office): | |
| Phone (Home): | |
| Email Address: |
Enclosed are my dues for (Thank You!):
| Individual/professional | ________ | $55.00 |
| Organization | ________ | $110.00 - $10 additional for each lodge |
| Student | ________ | $15 |