Membership Deactivation Request Form

To ensure the Association is aware of members who are no longer employed within a PA,PG or PC county program, and to keep our membership roster as up-to-date as possible, we ask that Supervisors and above complete the enclosed membership termination request form. Once received, the Association will archive the membership in question for one-year to ensure we have active certification records should that member rejoin a county PA|PG|PC program either in their original county or another in California. After one-year, records for that member will be removed from our database after which time that member would need to restart the certification process should they decide to rejoin a PA|PG|PC county program requiring membership with our organization.

Please note: all certification records are permanently kept on file for all past and present members to meet current federal and state requirments. Should you have any questions, please feel free to reach out to our team at info@capapgpc.org. Thank you in advance for your assistance in this matter.

Membership Deactivation Request

REQUIRED

Member Name (First & Last Name Only) to be terminated.*

REQUIRED

REQUIRED

REQUIRED

Date membership needs to be terminated*

REQUIRED

REQUIRED

Name of Supervisor/Manager requesting membership termination*

REQUIRED

Supervisor/Manager Email*


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REQUIRED

Today's Date (verification of date request submitted)*
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