SCNA Member Registration Form

Seattle Community Network Association (SCNA)
Member's Annual Registration/Renewal Form

P.O. Box 15387
Seattle, WA 98115

Member's Name: _ Phone:
Address:
Address:__
City: State/Prov:_
Zip/Postal Code:_ Country:
SCN User ID: _ Date:_ Renewal? [Yes] [No]
E-Mail address: ________________________________________________

In addition, SCNA's SCN project always needs additional funds. Please consider making a donation to cover costs, especially phone and hardware upgrades!
Donations will be published unless you check here _______ to make this donation anonymous.
The annual categories are (but if you can contribute additional funds, it will be most appreciated!):

_______ $500.00 Sponsor

_______ $250.00 Supporter

_______ $120.00 Standard
_______ $60.00 Sustaining

_______ $25.00 Basic
_______ $15.00 Low Income/Student

_______ (other, please specify amount)
_______ Additional Donation

_______ Total amount enclosed (make checks payable to SCNA)

_______ Please contact me, I would like to donate time (volunteer)

Thank you for taking the time to become a member of or renew your membership to the Seattle Community Network Association. Send completed membership form and check (made out to SCNA) to:

Seattle Community Network Association (SCNA)
P.O. Box 15387
Seattle, WA 98115

Membership dues and donations to SCNA are tax-deductible.

______________
SCNA USE ONLY
Received Date:
Amount:
Check #/Cash/Money Order:

Revised July 12, 2012 (rsg)

_______ $500.00 Sponsor	_______ $250.00 Supporter
_______ $120.00 Standard	_______ $60.00 Sustaining
_______ $25.00 Basic	_______ $15.00 Low Income/Student
_______ (other, please specify amount)	_______ Additional Donation
_______ Total amount enclosed (make checks payable to SCNA)	_______ Please contact me, I would like to donate time (volunteer)

Seattle Community Network Association (SCNA) Member's Annual Registration/Renewal Form

P.O. Box 15387 Seattle, WA 98115