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:

 

 

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)*

 

 

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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