M O B I L I Z I N G ST U D E N T S F O R A N E W EN…

    M   O B I L I Z I N G   ST U D E N T S F O R A N E W           EN L I G H T E N M E N T
         W W W . S          E C U L A R S T U D E                  N T S . O R G



                                                             Membership
                                                                  Form
Name:
(circle one) New / Renewal               If renewing, please update changed contact info.
Street Address:

City:                           State/Province:
Zip/Postal Code:                       Country:
Phone:(     )                                         Fax:( )
AIM:                                          MSN:
ICQ:                                          Yahoo!:
E-mail:
 If you do not have e-mail, we will send you written instructions on using your membership off-
line. Small additional fees for voting via paper ballot instead of online may apply. If you do not
                  have access to the Internet, you do not need to set a password.
Password:
 Your membership comes with a web based account that you can use to check your membership
 information and to vote for board members. New members need to select a password for this
 account. It should be between 8 and 16 characters long and contain both numbers and letters.
Membership type:
   Student ($10/year)                       Faculty or professional university staff ($25/year)
   Non-student ($35/year)                   First Year Alumni ($5/first year)
   Supporting member ($100/year)            Sustaining member ($250/year)
   Silver sponsor ($500/year)               Platinum sponsor ($1000/year)
   Lifetime membership ($1000)              Low-income membership ($10)
For joint memberships fill out TWO forms and include them in the same envelope. The fee
indicated is the total fee for the joint membership.
   Joint student ($15/year)         Joint non-student ($50/year)
Additional donation:
Total (membership + donation):
  Please do not trade my contact information with other organizations (we never sell)

 Make checks payable to "Secular Student Alliance" or pay by Visa/MasterCard
Card Number:
Expiration Date:

                48 Howard St.                              Fax/Voice Mail: 1-877-842-9474
              Albany, NY 12207                                 ssa@secularstudents.org

   The SSA is a 501(c)(3) educational non-profit and all dues are tax deductible.