Membership Application Name First Last Address Street Address PhoneMobileEmail Date of Birth Special InterestsLocal affiliationsI hereby apply to become a member of Camden Community Connections (CCC) Inc. Association. In the event of my admission as a member, I agree to be bound by the rules of the CCC Association for the duration of my membership. In the event that my application to become a member of CCC is accepted I will pay a membership fee of $5.00. Membership is due on 1 July each year and I understand that failure to pay the annual subscription within four (4) weeks of the due datewill result in the cessation of my membership. I understand that membership entitlements are not transferable to another person, and that entitlements terminate on cessation of my membership. I declare that I have never had an application to be a member of the CCC Association rejected.Signature of applicant: Drop files here or Date: As a member of CCC Inc. Association, I(Please print full name)Nominate the above applicant, for membership to CamdenCommunity Connections Inc. AssociationSignature of applicant: Drop files here or Date: Seconded by: As a member of CCC Inc. Association, I (Please print full name)Second the nomination of the above applicant for membership to Camden Community Connections Inc. Association.Signature of applicant: Drop files here or Date: Internal Use onlyNomination was referred to the Management Committee on Management Committee’s Determination approved / rejected (circle):Membership fee received on Receipt NoStaff Member’s NameDate NameThis field is for validation purposes and should be left unchanged.