CACCC ORGANIZATION REGISTRATION FORM

To join our coalition as an organizational member, please complete the form below and either email your completed form to info@caccc-usa.org or mail it to CACCC, P.O. Box 276, Cupertino, CA 95015.
ORGANIZATION INFORMATION
Organization Name (English/Chinese): _____________________________________________

Organization Acronym (if applicable): ______________________________________________

Address: ____________________________________________________________________
___________________________________________________________________________

Website: ____________________________________________________________________

Phone: (____) _______ - ___________ Toll-free number: (____) _______ - ____________

___ Check here to allow the CACCC to use the information listed above on our website as a Community Resource.
ORGANIZATION REPRESENTATIVE INFORMATION (for CACCC Internal Use Only)
Name (English/Chinese): __________________________________________________

Title: _________________________________________________________________

Business Phone: (____) _______ - ___________ (ext. _____)

Other phone (if applicable): (____) _______ - ___________

Fax: (____) _______ - ___________

Email: ____________________________________
Your signature below certifies that your agency agrees to become an Organizational Member of the CACCC.

X ________________________________________ DATE _______________
WHO WE ARE
The Chinese American Coalition for Compassionate Care, the only coalition in the nation devoted to end-of-life concerns in the Chinese community, is an active working coalition of 48 Partner Agencies and over 1,300 individual members.

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CONTACT US
EMAIL US (admin@caccc-usa.org)

TOLL FREE NUMBER
(866) 661-5687
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©CACCC, 2006