Please use this form for new memberships or renewal of an existing membership.
Membership Rates:
Individual – $15/yr. Family – $50/yr. Corporate – $100 and above I/we would like to become active in the CBCC. Please have a representative contact me/us.
I do not want to become a member, but I would like to make a tax-deductible contribution gift to the Connecticut Breast Cancer Coalition/Foundation in the amount of:
Name:
Date:
Organization:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
My contribution is: In Honor of In Memory of A Gift Membership to
(Name)
Send Acknowledgement to:
Please add me to the CBCC/F:
Mailing List
Please print and send to: The Connecticut Breast Cancer Coalition/ Foundation P.O. Box 509 South Windsor, CT 06074 Phone: (860) 984-6215 or Fax: (203) 886-1006 with any questions.
Thank you for your kind gift.
