Ind. MemberForm

APPLICATION FOR MEMBERSHIP IN CANA FOR THE YEAR 2008

NAME OF AFFILIATED ORGANIZATION                                                            

MAILING ADDRESS                                                                                                

NAMES, ADDRESSES, AND PHONE NUMBERS OF YOUR DELEGATES: e-mail addresses too if available.

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2.                                                                                                                                            

3.                                                                                                                                              

NAME OF INDIVIDUAL MEMBER                                                                        

MAILING ADDRESS                                                                                                

E-MAIL ADDRESS                                                                                                               

Please send this form and your annual membership fee ($25 per organization; $10 per individual) payable to CANA to Howard Stoller, 130 Melrose Avenue , Albany , NY 12203 by January 31, 2008 .