Membership Application

Use the form below to submit your application either by mail or electronically.When you hit continue you will be taken to a confirmation page. You can print the confirmation page and mail it to the address below or just click submit to email the registration.

WCCA
PO Box 1830
Lake Oswego, OR 97035

WCCA Tax ID 47-3268248
Dues ScheduleCompany / Individual Membership
Membership Dues$25

To determine your tier: count your Oregon workers’ comp technicians and supporting staff (managers, examiners, assistants, etc), those who manage or process claims, or are otherwise involved with claims management or workers’ compensation (case manager, risk manager, loss control, nurse case manager, vocational rehabilitation, etc).

Membership Application Form

Membership Form For *

Membership Year

Membership Dues

Payment Options

Check will be mailed within 5 daysCheck will be brought to the event

Contact Person Name *

First Name

Last Name


Company Name

Email Address *

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country


Phone Number

(###)-###-####

Fax Number

(###)-###-####

Business Type

If Other Please Describe

Add Others in your company to the mailing lists

Name

First Name

Last Name


Email Address

Name

First Name

Last Name


Email Address

Name

First Name

Last Name


Email Address

Comment / Questions: