New Family Membership Application If you choose manual payment method at the bottom of this form, make your check payable to “CCWR” and mail it to: CCWR P.O. Box 7203 Cotati, CA 94931 Login Information Username* An email address can be used as your username. Note that usernames cannot be changed and must be unique. Password* Type your password. Minimum length of 6 characters. Repeat Password* Type your password again. Primary Contact Salutation Mr.Mrs.Ms.Dr.Mr. & MrsNone First Name* Last Name* Suffix Dr.DVMJr.MDMSRVTNone E-mail* Confirm Email* Street Address* City* State* Zipcode* County* Choose from the list below:AlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaOut of State Region* Choose from the list belowRegion 1Region 2Region 3Region 4Region 5Region 6Out of State What CDFW region do you work in? A description of the regions is located at CDFW Regions. Phone* Phone (Alternate) Affiliation* What rehabilitation facility are you affiliated with? Website What year did you start in wildlife rehabilitation? Second Contact Info Contact 2 Salutation Mr.Mrs.Ms.Dr.None Contact 2 First Name Contact 2 Last Name Contact 2 Suffix Dr.DVMJr.MDMSRVTNone Email Permits and Areas of Expertise State Permits*No State PermitsBird BandingDisplay/ExhibitionFalconryNuisance Wildlife RemovalRabies Vector SpeciesRestricted SpeciesSalvage/Special PossessionThreatened/Endangered SpeciesVenomous ReptileWildlife RehabilitationWildlife EducationDo you hold any state permits? Federal Permits*No Federal PermitsBird BandingFalconryDisplay/ExhibitionRestricted SpeciesSalvage/Special PossessionThreatened/Endangered SpeciesUSDAWildlife EducationWildlife RehabilitationDo you hold any Federal permits? Areas of Expertise*Aerial InsectivoresAquatic BirdsBatsBobcatCaging (Design and Construction)Columbiformes (Doves and Pigeons)Corvids (Jays/Crows/Ravens)CoyoteDeer/FawnsEaglesEducationFosteringFoxFundraisingGamebirds (Turkeys and Quail)HawksHolistic/HomeopathyHumane Wildlife ExclusionHummingbirdsKilldeerNetworkingOiled WildlifeOpossumOwlsPasserinesRabbitRaccoonRaptors (other than eagle/hawk/owl)ReptilesReunitingSeabirdsShorebirdsSkunksSnakesSquirrelsSwallows/SwiftsWaterbirdsWaterfowlWoodpeckerNoneSelect no more than 3 areas. You must have at least 3 years of experience before adding an area to this field. Please note that members may use this information to help the public locate a rehabilitator and the information will be available in our online member directory. Other Areas of Expertise Other areas of expertise not already selected above. You must have at least 3 years of experience before adding an area to this field. Please note that members may use this information to help the public locate a rehabilitator and will be available in our online member directory.Preferences Do you want to be listed in the member directory?*Yes - List in the DirectoryDo not list Do you want to subscribe to the Gaggle Listserve?*Yes - subscribeNo - do not subscribeLIST SUBSCRIPTION IS NOT AUTOMATIC. TO BE ADDED TO THE LIST PLEASE SEND AN EMAIL TO WEBMASTER@CCWR.ORG. HOW IT WORKS When you send an email to firstname.lastname@example.org every subscriber will get the email message. If you reply to a message, every subscriber of the list will receive the email (like "reply all"). There will be a link at the bottom of each message you if you want to reply directly to the subscriber and not the entire list. It is good practice to include your name, location and affiliation on all messages. Only active CCWR members are allowed to participate in this unmoderated list.Family Member SubscriptionsChoose your level of membership. Family memberships allow two individuals to receive the special membership rate at the CCWR symposia and two votes during board elections. Family Membership - 3 years - $150 / 3 YearsFamily membership entitles two people from the household to the special membership rate at the symposium and two votes during board elections. Family membership for 3 years is $150.Family Membership - 2 years - $110 / 2 YearsFamily membership entitles two people from the household to the special membership rate at the symposium and two votes during board elections. Family membership for 2 years is $110.Family Membership - 1 year - $70 / 1 YearFamily membership entitles two people from the household to the special membership rate at the symposium and two votes during board elections. Family membership for 1 year is $70.Automatically renew subscriptionSelect a Payment MethodManual/OfflinePayPalNo payment methods are available for the selected subscription plan.Credit Card InformationCard Number*Card CVV*Expiration Date*123456789101112 / 2019202020212022202320242025202620272028202920302031203220332034Billing DetailsBilling First Name*Billing Last Name*Billing Address*Billing City*Billing Zip / Postal Code*Billing Country*AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the CongoReunionRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweBilling State / Province*Send these credentials via email.