Membership Registration Form

You have two payment options to register for CHFCC membership. You may pay with a credit card or a check.

If you choose to pay by Credit Card: Fill out registration form below; Select "Pay with Credit Card" Click "Continue" Click on the "PayPal" button

If you choose to pay by check: Fill out registration form below Select "Pay by check" Click "Continue" Print and mail registration form with your check payable to "Connecticut Center for Advanced Technology/CHFCC" and mail to: CCAT 222 Pitkin Street, Suite 101 East Hartford, CT 06108

Registration will be confirmed upon receipt of payment.

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* Company:
* Primary Contact First Name:
* Primary Contact Last Name:
* Title:
Department:
* Address:
* City:
* State:
* Zip:
* Phone:
Fax:
* E-Mail:
* Organization Description:	--- Choose one --- Original Equipment Manufacturer Materials/components/supplier Technical services Professional services Hydrogen production/storage/distribution Labor Customer (utility, power user, developer) Academic Government or gov’t related Non-profit Other
* Annual Membership Categories:	--- Choose one --- Premier, minimum - $2,500 Large Indusrty (>300 total employees) - $1,500 Medium Industry (100-300 total employees) - $750 Small Industry (<100 total employees) - $375 Academic - $375 Non-Profit/Other - $375 Government (ex Officio) - NC
Payment Method:	Credit Card       Check
* Agreement:	I certify by checking the adjacent box that I have read and understand the Articles of Collaboration which govern the Connecticut Hydrogen-Fuel Cell Coalition, and that I, as a member of such Coalition, do hereby agree to be bound by these Articles.