James M. Haussener, Executive Director

20885 Redwood Road, # 345, Castro Valley, CA 94546

Phone: 925-828-6215, Fax: 925-396-6005

E-mail: Jim@cmanc.com ~ www.cmanc.com

Should you have a change of address, please help us keep our records up-to-date and insure that you receive C-MANC mailings by completing this form and either mailing or faxing to the above address.

Name___________________________________________________________________

Title______________________________________________________________________

Organization_____________________________________________________________

Address__________________________________________________________________

Mailing address, if different________________________________________________

E-mail address, if different________________________________________________

City________________________________________________ Zip__________________

Phone________________________________________ Fax________________________

Effective Date________________________

Please print out and mail or fax this completed registration form to C-MANC