Name_________________________
Date_____________
Name
______________________________________________
Title of
Program____________________________________________
School / Organization
Name______________________________________________
School / Organization
Address____________________________________________
City__________________________
Zip_____________
Type of membership ___
Fellow $50 ___
Associate $35
( see attachment
A )
* Membership Year is
October 1 to September 30
Region # ________ (see
attachment B )
Phone
#_____________________
Email
Address_______________________________________
Is your program certified by New York
State? Yes or
No
Is your program one or two
years? 1
or 2
Number of years as an
Instructor. ________
Mail completed application with check
payable to CJS/TECI
c/o:
Bob Sternfeld
CJSTECI / Treasurer
2 Pinehurst Drive
Clifton Park NY
12065
