Official SCOPE Membership/Donor E-Form

Please fill in the form below. You will be sent a bill for membership (alas, we don't yet have online payment methods) and when the check clears you will be a member. If a donation, we'll bill you for your pledge.

 Donation Information

Do you want to be a member, a donor, or both?

Donation type:

Member Donor Both

Option 1 - If you want to be a member, please fill out the following:

Regular Single Membership ($25/y)

Regular Family Membership ($35/y)

Option 2 - If you want to be a donor, please fill out the following:

$10

$25

$50

$75

$100

(Other)

(Other amount)

Value of pledge; omit the dollar sign ($).

Option 3 - If you want to do both, fill out both of the above

 Personal Information

Please fill out the following. Items marked with an asterisk (*) are optional.

NOTE:
If this is a family donation, you can use "The Smith Family" in Last Name, or "John and Martha" in First Name (latter is preferred)

If you are making a donation for an organization, enter the organization's name in Last Name.

Prefix (Mr. Mrs. Etc)*

Mr. Mrs Ms Mr&Mrs Hon.

First Name

Middle Name

Last Name

Suffix (Sr. Jr. Etc)*

Street Address

Apart/Unit

City

State/Province

Zip/Postal Code

Home Phone *

Work Phone *

Fax Phone *

Mobile Phone *

Pager Phone *

E-mail *

Useful skills for SCOPE *

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