ACCCTEP
Association of California Community College Teacher Education Programs
"Inspiring and educating tomorrow's teachers."
Membership Application
ACCCTEP Membership and Renewal Application
(COPY and PASTE THIS APPLICATION onto a blank WordDoc; complete it; email it as "Attachment" to: khenkins@mtsac.edu)
* = Required Field
Are you joining as a new member or renewing your current membership?*
*_____I am joining as a new member.
*_____I am renewing my current membership.
Which TYPE of membership you are requesting?*
*_____INSTITUTIONAL MEMBER (by district or by individual colleges)
$100 (two people, minimum)
$50 (each additional person)
*_____INDIVIDUAL MEMBER
$60
*_____AFFILIATE MEMBER: (not from a California community college; may be a K-12 person or from a four-year institution; will be a non-voting member)
$50
HOW MANY of each type are you registering today?*
*_____Institutional Members (2 minimum; more may be added later)
*_____Individual Member
*_____Affiliate Member
Please complete the following information for EACH member:*
*Prefix: ___Dr. ___Mr. ___Mrs. ___Ms.
*First Name:
*Last Name:
*Position/Title:
*College:
*Campus:
College/ Department Web Site :
*Address:
*City:
*State:
*Zip:
*Work Phone Number:
Fax Number:
*Email Address:
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*Prefix: ___Dr. ___Mr. ___Mrs. ___Ms.
*First Name:
*Last Name:
*Position/Title:
*College:
*Campus:
College/ Department Web Site :
*Address:
*City:
*State:
*Zip:
*Work Phone Number:
Fax Number:
*Email Address:
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*Prefix: ___Dr. ___Mr. ___Mrs. ___Ms.
*First Name:
*Last Name:
*Position/Title:
*College:
*Campus:
*Address:
*City:
*State:
*Zip:
*Work Phone Number:
Fax Number:
*Email Address:
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*Prefix: ___Dr. ___Mr. ___Mrs. ___Ms.
*First Name:
*Last Name:
*Position/Title:
*College:
*Campus:
*Address:
*City:
*State:
*Zip:
*Work Phone Number:
Fax Number:
*Email Address:
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Please review this form carefully. Make sure all information provided is correct.
COPY and PASTE THIS APPLICATION onto blank WordDoc; complete it; email as "Attachment" to: khenkins@mtsac.edu
Upon receipt of membership application, the Primary Member(s) will receive a confirmation.
If you have any questions, please contact: aperlstein@elcamino.edu
Cerritos College Foundation Tax ID # is 95-3387108
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Method of Payment* (CHOOSE ONE):
*_____I am sending ACCCTEP a check.
ON THE MEMO LINE, PLEASE WRITE: “ACCCTEP Membership”
Please submit payment by check to: CERRITOS COLLEGE FOUNDATION and mail to:
Cerritos College Foundation, attn. JANICE COLE
11110 Alondra Blvd.
Norwalk, CA 90650-6298
*_____I am using a Credit Card.
Please call Janice Cole to pay over the phone (562) 860-2451, ext. 2526 or fax your credit card information (name, credit card number, expiration date) to 562-467-5041. (Please tell her payment is for ACCCTEP Membership.)
When paying by credit card, your statement will reflect a charge from Cerritos College Foundation.
