Membership App.
Please print and sign
Fax: 818-700 0538
9772 Cactus Ave. Chatsworth, CA. 91311
Membership Application
Owner's Name: ________________________________________________
School Name: _________________________________________________
Date Established: ______________________________________________
Address: _____________________________________________________
City: ________________ State: _______________ Zip: _______________
Mailing Address (if different from above): ____________________________
City: ________________ State: _______________ Zip: _______________
E-mail: _______________________________________________________
Website: _____________________________________________________
Telephone: ( _____ ) _______________ Fax: ( _____ ) ________________
Program Offered: _______________________________________________
Legal Status of School:
___ Sole Proprietorship ___ Partnership ___ Corporation
___ Joint Venture ___ Other : _________________________
___ BPPVE Approved ___ Voluntary Agreement
Number of Basic And Advanced Graduates:
2006 _____________
2007 _____________
2008 _____________
I confirm that this information is true to the best of my knowledge and can be carifird. I undertstand that CAMSA members are required to maintain the highest standards of professional manner and strictly adhere to its Code of Ethics.
____________________ ______________________ __________________
Print Name Signature Date
Please print and sign
Fax: 818-700 0538
9772 Cactus Ave. Chatsworth, CA. 91311
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