Application

Membership Applications

Local Association Applications are below

Representative Name:
Company Name:
Address:
City/State/Zip:	,
Telephone:
Fax:
E-Mail / Website:	E-Mail: Website: Website:
Year Company was established:
Business Category:
License Type / Number Classification (s): (use the Control key to make multiple choices)	License Type: License Number: Renewal Date: Classification (s): Classification (s):
Type of Business: (use the Control key to make multiple choices)
# of Technicians:
Membership Category:	Local/State/NA (dues are paid to locals) At-Large ($38 per month + $15 per month Free Enterprise Fund Assessment state / PHCC-NA $456.00 annually for 2007) Affiliate ($38 per month + $15 per month assessment)
Dues Payment Option:	Check Visa MasterCard
Dues Payment Plan:	Monthly Quarterly Semi-Annually Annually
Credit Card # / Exp. Date:	Exp. Date
Local Association:
How did you hear about us?	Other:

Note: Dues are subject to change.

Local Association Membership Applications and Dues Information

At-Large Membership

PHCC of Alameda & Contra Costa Counties

PHCC of the Greater Los Angeles Area

PHCC of Orange, Riverside & San Bernardino Counties

PHCC of the Redwood Empire

PHCC of the Sacramento Valley

PHCC of San Diego

PHCC of San Francisco

PHCC of Ventura

Affiliate Member Application (pdf version)

If you are in a geographic area that has a local association, you must join directly through the local association (applications submitted via the internet will be forwarded to the appropriate local association). If you are joining a local association, please withhold payment, as you will be billed by the local association. If you are an At-Large member, please submit payment. If you are paying by check, please complete the application on this page and print the form out and send it with your check to:

PHCC of California
4153 Northgate Blvd., Suite 6
Sacramento, CA 95834
(916) 925-7390
(916) 925-7623 - fax