CCIVA Membership Form 2019
6641 Ironbridge Parkway, Chester VA 23231 | 804.536.2524 |

CCIVA is a leading non-profit organization that carves and hosts numerous unique programs to serve the community in Central Virginia, bringing everyone together under one roof to share our culture & roots.
Membership allows you and your family to take advantage of many unique events we bring to the community!
For calendar of events, volunteering opportunities and more please visit official website
Form must be completed and fees must be paid to sign up for calendar year Jan 1st to Dec 31st 2019.
Family membership: $150 annual fee - Family with unmarried kids and retired grandparents of 70 yrs & above living in one household included.
Single: $75 annual fee for single person.

Email address *
Spouse's Email Address
Your answer
Membership Options *
First and Last Name *
Your answer
Spouse's Name
Your answer
Street Address *
Your answer
City, State & Zip Code *
Your answer
Phone Number *
Your answer
Full Names of Unmarried Children with Date Of Birth (Month/Year)
Your answer
Names of Retired Parents (living under same household & 70+ yrs of age) - included in family membership
Your answer
I would like to include my Name, Address, Phone number in Taste Of India Book *
Where did you hear about us?
Applicant Signature (Print Full name) *
Your answer
Date of Application *
Payment is due when form is filled *
A copy of your responses will be emailed to the address you provided.
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