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

P.O. Box 947
Seattle, WA 98111-0947

Member's Name: _________________________________ Phone:________________

Address:______________________________________________________________

Address:______________________________________________________________

City:______________________________________ State/Prov:_______________

Zip/Postal Code:_______________ Country:__________________

SCN User ID: ___________________ Date:_______________ Renewal? [Yes] [No]

E-Mail address: ______________________________________________________

The annual categories are (but if you can contribute additional funds, it will be most appreciated!): Phone Sponsor (500.00), Phone Supporter (250.00), Patron (100.00), Family Membership (50.00), Basic Membership (25.00), or Low Income/Student Membership (15.00).

Phone Sponsors may submit a 5-line message that displays to users on login:

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

In addition, the SCN project always needs additional funds. Please consider making a donation to cover costs, especially much-needed phone and hardware upgrades!

Donations will be published unless you check here _______ to make this donation anonymous.

_______ $500.00 Phone Sponsor

_______ $250.00 Phone Supporter
_______ $100.00 Patron
_______ $50.00 Family Member
_______ $25.00 Basic Member
_______ $15.00 Low Income/Student
_______ (other, please specify amount)
_______ Additional Donation

_______ Total amount enclosed (make checks payable to SCNA)

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 947
Seattle, WA 98111-0947

Membership dues and donations to SCNA are tax-deductible.

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