Membership Application Apply to become a member of the Santa Maria Women’s Network Contact DetailsName(Required) First Last Individual or Corporate?(Required)IndividualCorporateBusiness Name(Required)Title(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Phone(Required)Mobile Phone(Required)Website(Required) Email(Required) Brief Description of Business(Required)How did you hear about us?(Required)Would you consider serving on our Board of Directors?(Required) Yes No Payment Method(Required)(CREDIT CARDS) Enter information on this form for us to run manually OR you may visit www.smwn.net/join and utilize the PayPal widget to complete your credit card payment online. Cash or Check Credit Card How will we expect to receive your cash or check?(Required)Submit in person to our Meeting Coordinator at a Monthly Meeting or mail to SMWN, P.O. BOX 5242, SANTA MARIA, CA 93456‐5242. Make checks payable to SMWN.Select OneI will submit in person to Meeting Coordinator at a Monthly MeetingI will mail to your PO BoxHow would you like to submit your credit card for processing?(Required)Select OneI will give you the information to run on your endI would like to complete it through your online PayPal widget at www.smwn.net.joinCredit Card #(Required)Name on Card(Required)Expiration(Required)CVC #(Required)Zip Code(Required)Visit www.smwn.net/join after you submit this form to utilize our PayPal Widget to submit your payment.(Required) Okay, will do! Signature(Required)Your typed name, below, will serve as your signatureToday's Date(Required) MM slash DD slash YYYY Member Dues ProratedMembership is valid for one year, July 1 through June 30. Dues are prorated based on the month of sign up. Pay these dues to activate your membership through June 30th: July-$120.00; August-$110.00; September-$100.00; October-$90.00; November-$80.00; December-$70.00; January-$60.00; February-$50.00; March-$40.00; April-$30.00; May-$20.00; June-$10.00PhoneThis field is for validation purposes and should be left unchanged. Δ
