SCNA New Membership Application

P.O. Box 8366, Calabasas CA 91372-8366  *  (818) CAL-BARE * (818) 225-2273

Name _____________________________________________________________________
Last First M.I. Mailing Address __________________________________________________________________
City State ZIP Telephone ( ____ )________________ ( ____ )________________ ( ____ )________________
Home Work Cell
You may contact me using the above mailing address? Yes_____ No_____
Email ____________________________________________________________________
You may contact me using the above email address? Yes_____ No_____
If "No" to both, how do we communicate with you? _________________________
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 $____________ *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 make check payable to: SCNA.
Your Gender: [ ]Male [ ]Female Date of Birth: Mo:____Day:____Year:____
Spouse/Partner's Name: ________________________________________ 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[ ]
[ ]No [ ]Yes Have you ever been convicted of any felony? If yes, please provide details on the back of this form.
I swear the above information is true and correct,
Signature of applicant: _____________________________________
Signature of Spouse/Partner: _____________________________________
NOTE: Please be aware that for the protection of our members, all applicants are subject to a background check. For identification purposes, please provide a copy of your current driver's license and a current photograph with this form.

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Mail: P.O. Box 4962, Panorama City, CA 91412-4962