CACAD
Capital Area Consortium on Aging and Disability
29 Dartmouth Street, Albany, NY 12209

ANNUAL MEMBERSHIP APPLICATION/RENEWAL

Name:  ______________________________________________________________

Title:  _______________________________________________________________

Organization:  _________________________________________________________

Address:  _____________________________________________________________

City: ____________________________  State: _____  Zip Code: _____________

Phone # _________________________  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; ____ 

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/