Membership Form

Members' donations are 100% tax deductible.

To become a member of CIIN and receive Our Toxic Times, please complete the following and submit with payment:

Name

New Member Renewing Member Past Member

Address

City

State

Zip or Postal Code

Country (if other than U.S.A.)

Phone

Email address

Please charge my membership donation of
(Not less than $25 please) to my credit card.

CIIN accepts MasterCard, Visa and Discover cards:

Name on the Credit Card

If this is a gift, please include recipient's name:

Credit Card Number (Example: XXXX-XXXX-XXXX-XXXX)

Please include the 3 digit security code from the back of the credit card

Card Expiration Date (Month/Year)

Please keep my membership anonymous

Please keep my donation anonymous

Please mail me a receipt for my donation. (For donations of $50 and over)