Califa: Membership Application

Membership Application / Renewal Form

General Information
Are you a new applicant or a renewing member? Please check one of the following:
New member Renewing Member

Library Type:
Academic Public School Special/Other

Library Name

Parent Organization

Address Line 1

Address Line 2

City

State

Zip

Website

Administrator/Member Contact
Library Director

Title

Phone

FAX

eMail

Electronic Services Contact
Name

Phone

FAX

eMail

Purchaser/Other Authorized User Contact
Name

Phone

FAX

eMail

Library Information
Number of FTE Staff

Number of Branches

Number of registered borrowers or students

Number of juvenile borrowers

Membership Fees

Invoice/Bill to Information*

(*if different from Administrator Contact above)

Invoice Name

Title

Invoice Address Line 1

Invoice Address Line 2

City

State

Zip

Payment Information

Check
Please print this form & enclose check for:

$__________

Mail to:
Califa Group
32 W. 25th Avenue
San Mateo CA 94403

Credit Card
Please print this form, then fill out the following credit card information:

Name on card:

____________________

Number:

____________________

Exp. Date: ____ /____

Fax to:
Califa Group
650.572.2746

Invoice
Make sure invoice information is complete above. Fill out purchase order information if necessary and submit online.

Purchase Order:

For help call 866.209.5439 (CA toll free) or email califa@califa.org.