Name_________________________ Date_____________
Name ______________________________________________
Title of Program____________________________________________
School / Organization Name______________________________________________
School / Organization Address____________________________________________
City__________________________ Zip_____________
Type of membership ___ Fellow $50 ___ Associate $35
( see attachment A )
* Membership Year is October 1 to September 30
Region # ________ (see attachment B )
Phone #_____________________
Email Address_______________________________________
Is your program certified by New York State? Yes or No
Is your program one or two years? 1 or 2
Number of years as an Instructor. ________
Mail completed application with check payable to CJS/TECI
c/o:
John Pecora
CJSTECI / Treasurer
P.O. Box 541
Johnstown, NY 12095
