(SCAW) Institutional Membership Form

Institutional Membership Form

Order options:

Or print this form and mail to: SCAW

7833 Walker Drive, Suite 410

Greenbelt, MD 20770

tel: 301-345-3500, fax: 301-345-3503

____ Level A: $5,000 annual fee includes three free registrations at SCAW meetings, discounts on additional registrations and at SCAW meetings and 25 copies of each issue of the SCAW Newsletter for 12 months following new or renewal of membership.*

____ Level B: $2,000 annual fee includes two free registrations at SCAW meetings, discounts on additional registrations at SCAW meetings and 20 copies of each issue of the SCAW quarterly Newsletter for 12 months following new or renewal of membership.*

____ Level C: $1,000 annual fee includes one free registration at SCAW meetings, discounts on additional registrations at SCAW meetings and 15 copies of each issue of the SCAW Newsletter for 12 months following new or renewal of membership.*

____Level D: $500 annual fee includes discounts on registration fees at SCAW meetings and 10 copies of each issue of the SCAW Newsletter for 12 months following new or renewal of membership.*

(New members receive a plaque and certificate of membership and educational CD. Renewing members receive a current certificate.)

Representative Name/Title:
________________________________________________

________________________________________________

Institution Name:

________________________________________________

StreetAddress/City/State/Zip:

________________________________________________

Telephone/E-mail/Fax:
________________________________________________

Select method of payment:

( )check ( )master card ( )visa (American Express is not accepted)

Card number

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Expiry date

__ __ __ __

Name of cardholder

_______________________________________

Authorized signature

_______________________________________

Please mark off the appropriate membership level and return the completed application with your check payable in U.S. funds on a U.S. bank to SCAW. Mastercard and Visa payment is also acceptable; please call the SCAW office. American Express is not accepted.