Registration Form TEST PAGE "*" indicates required fields Step 1 of 3 33% Organization InformationOrganization*CAN (If Applicable)Select CANCentralEasternFairfieldHartfordMMWNew HavenNorthwestAgency Type / Sector Homeless Service Provider CAN Backbone / Lead State Agency Municipal Healthcare Other Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Membership* We are NOT a CCEH Member We are a CCEH Member We are not currently a Member, but will pay for Membership in this form. Annual BudgetMembership is based on Organization Annual Budget (or portion of budget devoted to homelessness). Org. Budget < $1M - ($250) Org. Budget $1M-$5M - ($500) Org. Budget >$5M - ($1,000) Click HERE to see a list of current CCEH Members. Members marked with an asterisk have not yet renewed in 2025. RegistrationRegistrants Name Lunch Choice Dietary Restrictions Actions Edit Delete There are no Registrants. Add Registrant Maximum number of registrants reached. Registrants Name Lunch Choice Dietary Restrictions Actions Edit Delete There are no Registrants. Add Registrant Maximum number of registrants reached. PaymentATI Registration Total Price: $0.00 ATI Registration Total Price: $0.00 Membership TotalTotal Payment Type* Invoice Credit Card Coupon Credit CardCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Send Invoice / Receipt to:* First Last Email for Invoice / Receipt:* Enter Email Confirm Email Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code