Community Assessment

Name *

Telephone Number *

Email Address

Address *

Address

City

State/Province

Zip/Postal

Country

Membership Status

New Member

Renewal

Membership Level *

Payment Options *

Pay by check – Mail to: Curry Coast Community Radio, PO Box 565, Brookings, OR 97415

Pay in person – I will wait to be contacted for further instructions

Pay using a credit card or PayPal (click the "Donate" link at the upper-right of the page)

OtherOther

Recognition/Contact Options *

List my name on any publication as a KCIW Member

I wish to remain private – Please do not list my name on any publications or website

I would like to receive information from KCIW via email

Please do not contact me

OtherOther

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