CSCA Membership Application

Certification

(Required ONLY if applying for Active Membership)

As the Coroner or Medical Examiner of   County in the State of California, I hereby certify the above applicant meets the requirements for Active Membership in the California State Coroners’ Association.
Date:

Name: 

Title: 
Sign: ______________________________________
Fill out the form, Print The Form, (don’t forget to sign it), then mail it with check payable to CSCA to:

Robert Foucrault, CSCA EXECUTIVE SECRETARY, 211 Bradbury Lane, Redwood City, CA 94061