CONTRIBUTION SUBMISSION FORM

If you are able to donate at least $50, we would like to thank you by sending a commemorative pin representing California's status as the last state without Professional Counselor Licensure.

Become a:
_____
 Licensure Visionary ($100+)
_____
 Licensure Leader ($100)
_____
 Licensure Professional ($75)
_____
 Determined Advocate ($50)
_____
 Supportive Friend (Whatever you can!)
_____
 Graduate Student (Whatever you can!)

Contact information will be used only for CCCL purposes.


Name:

_____________________________

Email Address:
CCCL communicates through email:
 _____________________________

Home Address:
Your home address determines your Legislative District:
 _____________________________

Home Zip Code:
Your home address determines your Legislative District:
 _____________________________

Home Phone:
 _____________________________

Work Phone:
 _____________________________

Please sign if CCCL
may use your name
as a supporter:
 _____________________________

*Your State
Assembly Member:
 _____________________________

*Your State Senator:
 _____________________________


*If you do not know the name(s) of your California State Legislative Representatives, click here (www.senate.ca.gov) to search the official directory. Be prepared to enter your home address.



Please print the above page and mail it along with your check made payable to: CCCL

Mail to:
CCCL
PO Box 6493
Ventura, CA 93306-6493

Your contribution will be used: 80% for legislative activities (including lobbyist fees), 20% for educational activities (counselors, consumers). Please consult your tax advisor regarding the tax benefit of your contributions.

Thank you for your support!

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