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FCCAM Supporter Center Membership Application - Class D
FCCAM also welcomes Maine’s legally operating Facility Directors and their staff who want to support the work of FCCAM.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Facility Director Name (First, Last)
*
Your answer
Facility Staff Name (First, Last) *if not Director
Your answer
Email
*
Your answer
Best Contact Phone Number
*
Your answer
Facility / Center Name
*
Your answer
Facility / Center - Physical Address: Street / City / Town / Zip Code
*
Your answer
Facility / Center - Mailing Address (if different from Physical AddressCity / Town / Zip Code
Your answer
Facility / Center County
*
Androscoggin
Aroostook
Cumberland
Franklin
Hancock
Kennebec
Knox
Lincoln
Oxford
Penobscot
Piscataquis
Sagadahoc
Somerset
Waldo
Washington
York
Facility / Center License Capacity
*
Your answer
Class D Non-Voting Supporter Membership (annual)
Facility / Center Director Supporter Membership (non-voting) - $15
Facility / Center Staff Supporter Membership (non-voting) - $15
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Payment
*
PayPal Invoice
I will mail a check to FCCAM, Attn: Courtney-Jo Arrants, 91 Gravy Lane, Bradford, ME 04410
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