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.