SCCP Coordinator Registration Form

Please complete this form by no later than July 21, 2017. The Coordinator listed on this form will be the primary point of contact for your agency during the 2017/2018 campaign. Training will begin in August and the campaign will run from September 5 - November 17, 2017. The general information provided below will be used to determine the supplies needed for your campaign and the award winners in the Spring. Campaign materials will be shipped directly to the address provided below within 7-10 business days. Your payroll administrator is essential because they are the main point of contact for payroll deductions.
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    Coordinator Information

    Please provide information regarding the person(s) who will be coordinating your SCCP campaign this year.If you have more than one Coordinator, list the primary point of contact first, then list the additional person in the Secondary Coordinator field.
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    Agency/University Information

    Please list the information below specific to your Agency/University. When providing your address, please do not list post office boxes as courier services are used for delivery.
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    Other Agency Information

    Collected and used to mail out marketing materials
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