2012 2013 membership forms (PDF)

Asian Pacific American Coalition of Connecticut
Membership Registration Form 2012-2013
Visit our website www.apac-ct.org for more information about upcoming events!
Prefix

First Name

Suffix  

Last Name

Member Name
Street Address
City/State

Zip/Postal Code

E-mail Address
Telephone
Ethnicity (optional)
Employer
 

MEMBERSHIP
APAC is a 501(c)3 non-profit organization. Membership dues are not tax-deductible. Donations are tax-deductible and
may be eligible for employer-matching programs. Membership period is July 1, 2011 through June 30, 2012.
Number of
Category
Suggested
Amount
Memberships
Dues
Enclosed

 

Individual

$25

 

 

Student

$10

 

 

Retiree

$10

 

 

Family (up to 3 additional members)

$40

 
 

Additional Donations (tax-deductible)  

TOTAL  
 

Family Membership- Please list up to 3 additional names for family membership.
Name

 
 
 
 

E-mail Address
 
 
 

Relationship
 
 
 

AFFILIATIONS
List up to 3 other relevant affiliations (e.g. boards, coalitions or associations) that address the
interests of the APA community.
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________

Please make checks payable to “Asian Pacific American Coalition of CT”
and mail to:
APAC of CT, PO Box 674, Manchester, CT 06045