CCNMA Membership Application
NEW MEMBER
RENEWAL
Name: 
Job Title: 
Company: 
Co. Address: 
City:   State:   Zip: 
Office Phone:   Fax: 
Email: 
Home/Permanent Address: 
City:   State:   Zip: 
Home Phone:   Fax: 
E-mail: 
Which address do you prefer CCNMA correspondence be mailed:  HOME      WORK      SCHOOL 
STUDENTS ONLY
School: 
School Major: 
Year in school:    Expected graduation date: 
Mailing address at school: 
City:   State:   Zip: 
School phone:   Fax: 
E-mail: 
MEMBERSHIP CATEGORIES
ASSOCIATE AND STUDENT MEMBERS DO NOT CARRY VOTING PRIVILEGES 
  JOURNALIST Professional reporters, writers, editors, producers, photographers $50  Annual dues
  ASSOCIATE  Non-journalists: public relations, marketing, academic professors  $50  Annual dues
  STUDENT  Full-time college or graduate school students $20  Annual dues
  SPOUSE/RETIRED
 Non-journalist spouse or retired journalist no longer working
 $25  Annual Dues
  LIFETIME
Available to Journalist or Associate members only
 $1,000   (one time payment, or 10 monthly payments charged to a credit card)
  2-YEAR MEMBERSHIP
 Available to Journalist or Associate members only
 $90
Ethnicity (for statistical use only): 
Are you in?  Print    Broadcast    On-line
How long have you been a professional journalist? 
CHAPTERS
Choose the chapter you wish  to join.  If there is no chapter in your area, choose At-Large.
Central Valley (Bakersfield,   Fresno)
 San Jose/San Francisco
 Los Angeles (includes Orange County)
San Diego At-Large

ACTIVITIES
I want to get involved with:
Newsletter
 Fundraising
 Scholarship judging
 High school workshops
JOC
 Scholarship banquet
 Speakers bureau
 Membership drive
PAYMENT
Check made payable to CCNMA enclosed. 
Bill my credit card:

 American Express  Mastercard  Visa

Account number:

Name on card (print):  

Expiration date:

Signature:_______________________________________________
Enclosed is my check/money order payable to CCNMA for  $  for membership, and my tax-deductible contribution to support CCNMA's programs for
$ .  TOTAL ENCLOSED:  $ .

Signature _______________________________________________________     Date ______________________________
FOR OFFICE USE ONLY
Date received:_______________
 Amount received:_______________ Membership card and pin sent:_______________
RETURN THIS FORM WITH PAYMENT TO:
CCNMA • USC Annenberg School of Journalism  • 727 W. 27th St., Rm. 201 • Los Angeles, CA  90007-3212
Phone:  (213) 821-0075 • Fax:  (213) 743-1838  • Email:  ccnmainfo@ccnma.org •  www.ccnma.org
CCNMA is a 501(c)(3) Tax-exempt nonprofit organization, Federal I.D. 95-3020829