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

P.O. Box 15387
Seattle, WA 98115

Member's Name: _________________________________ Phone:________________



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.

Received Date:
Check #/Cash/Money Order:
Revised July 12, 2012 (rsg)