Full Name: ________________________________________________________
Mailing Address: ________________________________________________________
City/State/ZIP: ____________________________________, _______ __________
Telephone: (____)____________ (____)____________ (____)____________
Home Work Cell
May We Contact You at this mailing address? ___ Yes ___ No
Email#1 (home):____________________________________________________________
May We Contact You at this email address? ___ Yes ___ No
Email#2 (work):____________________________________________________________
May We Contact You at this email address? ___ Yes ___ No
If "No" to both, how do we communicate with you?
___________________________________________________________________________
Your Gender: ___ M ___ F Your Date of Birth: Mo:___ Day: ____ Year ____
Check the appropriate box(es):
______ Individual Membership/year $ 95.00*
______ Couples/Family Membership/year
(no charge for children under age 18)
Defined as two adults at same mailing address $ 190.00*
______ First-Time Membership Processing Fee
(first year only, or if membership has lapsed.) $ 35.00
________________
Total $
Please make check payable to: SCNA
Sorry we are not able to accept credit card orders at this time.
(There is a $15 fee charged for all returned checks.)
*Some activities may require additional fees. Once your membership application
is approved, Membership Fees are non-refundable. We allow a 30-day grace period
after the expiration date for membership renewal.
Please Complete this section if you are applying as a couple or family:
Spouse/Partner’s Name ______________________________________
Partner Gender: ___ M ___ F Partner DOB: Mo:____ Day: _____ Year ______
Address (if different than above) ______________________________________
Partner Voice Phone: ______________________________________
Partner Email: ______________________________________
Any Children under age 18?:
Name: ________________________ Age _____ ___ M ___ F
Name: ________________________ Age _____ ___ M ___ F
Name: ________________________ Age _____ ___ M ___ F
Name: ________________________ Age _____ ___ M ___ F
Have you or your partner ever been convicted of any felony? ___ No ___Yes
If yes, please provide details on the bottom of this form.
I swear the above information is true and correct,
Signature of applicant: _____________________________________
Signature of Spouse/Partner: _____________________________________
NOTE: For the protection of our members, all applicants are subject to a
background check. Please submit a recent photo and a copy of your
Driver’s License (both sides) with this application.
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