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To become a CPA member print this application, fill it in and send it, along with your check, to the address listed below.

2011 MEMBERSHIP APPLICATION

Name _____________________________________________________

Address ____________________________________________________

City                                                     State                        

Zip______________

Daytime telephone  (           )                                                               

Employer _____________________________________________________

If you would like to receive "save the date" information, program brochures, newsletters by email please include your email address. Your email address will not be shared with any other organization or company.

 E-Mail address:                                                                                 

Referred by:                                                                                        

 CPA MEMBERSHIP DUES: $25.00

MAKE CHECKS PAYABLE TO: CPA

MAIL TO:

Gwyn Muscillo

UConn Health Center - MC2210

263 Farmington Avenue

Farmington, CT 06030 -2210

FOR INFORMATION CONTACT:

Jane Montgomery . . . jtmontgomery37@cox.net