CACAD
Capital Area Consortium on Aging and Disability
29 Dartmouth Street, Albany, N.Y. 12209

ANNUAL MEMBERSHIP APPLICATION/RENEWAL

Name: ______________________________________________________________

Title: _______________________________________________________________

Organization: _________________________________________________________

Address: _____________________________________________________________

City: ____________________________ State: _____ Zip Code: _______________

Phone # – Work _________________________ FAX _________________________

E-mail address: ________________________________________________________

CATEGORY OF MEMBERSHIP

Please check one: ____ New Member; ____ Renewal

Please check here if you are available to help on CACAD committee work: _____

Select one of the following you wish to represent:
____ Provider; ____ Consumer; ____ Education/Research; ____ Government;
____ Business; ____ Religious Organization; ____ Union; ____ Other (____________)

Individual Categories:____ Student/Retiree $10; ____ Regular $25; ____ Sponsor $50

Organizational Categories:
____ Basic $100; ____ Supporting Member $200; ____ Sustaining Member $500
____ Network Supporter $1,000; ____ Network Patron $5,000

Method of Payment: ____ Cash; ____ Check; ____ Visa; ____ MasterCard

Visa/MasterCard # ______________________________ Exp. Date ________________

Please return your completed form and payment to CACAD at the above address.

Thank You

Visit and participate in the new CACAD Web site at www.cacad.org
and online Care Directory at www.cacad.org/care/