CIIN Membership Form

You must be a member of CIIN before ordering library materials. Thank you for joining.

- NEW MEMBER
- RENEWING MEMBER
- PAST MEMBER
- GIFT
Donation Amount

How do you want to receive the newsletter?

E-MAIL
PAPER

Our Toxic Times

Payment Information

Card Type
- VISA
- MASTERCARD
- DISCOVER
Name on Card
Card number
Expiration date
security code

Member Information

Name
Billing Address
Mailing Address
City
State
Postal Code
Country
Email
Phone

Would you like to share your information with members?

NO
YES

Gift Recipent Info - (Fill out only if you are giving as a gift:)

Name
Address
City
State
Postal Code
Country