Champa Cultural Preservation Association Of U.S.A

CHAMPA CULTURAL PRESERVATION ASSOCIATION OF U.S.A

P.O Box 56240, San Jose, CA 95156-56240
         Phone: (408) 258-4202 or (916) 395-3754 or (408) 281-7062
  Fax: (916) 395-3754 Email: ccpaoffice@ilimochamp.org
Web-mail: webmaster@ilimochampa.org
    Web site: www.ilimochampa.org

MEMBER REGISTRATION

First Name: Last Name: Sex:

Address:

City:                           State:      Zip:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email Address :

I would like to apply for a membership of Champa Cultural Preservation Association of U.S.A; it is the responsibility for every people who has ardor with Champa nation. Becoming a member of the CCPA, I promise to put myself in the Culture of Champa.

Date:

Signature:

First Name: Last Name: Sex:

Address: City: State: Zip: Country:

Address:

City: State: Zip:

Country: