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SCBA Membership Enrollment Form

SCBA Membership Registration/Renewal Form

To be used for on line SCBA Membership Enrollment or Renewal

Suffolk County Bar Association requests that you to complete the following application so that we may register you, or renew your membership in the association. Please note that the information contained herein is transmitted to us through a secure site. If you have any questions you may contact us:
(631) 234-5511 (ext. 221), or E-Mail us at

Date of Request *: Please use mm/dd/yy format
E-mail Address*:
Office Address *:Street address:

City: State: Zip:

Home Address:* Street address:

City:   State:   Zip:

Office Phone (with area code)*:
Home Phone (with area code):
Cell Phone (with area code):
Fax (include area code):
Indicate which address you prefer listed in the annual directory*: Office       Home
Indicate which address you prefer Bar Association mailings be sent*: Office      Home
Applicant's gender*: Male        Female
Applicant's Date of Birth*: Please use mm/dd/yy format
Date admitted to practice*: Please use mm/dd/yy format
in the State(s) of*:
Admitted in what department*:
I wish to be considered for appointment to the following committee(s):

(you may choose multiple committees by clicking on your choices while keeping the "Ctrl" key depressed - scroll to see all choices)

* Closed Committee membership is subject to appointment and Board of Director's approval


Type of Application*: New member , Membership renewal
SCBA Member ID#: If this a renewal please enter your 6 digit Member ID#
I am applying/renewing*:    (CLICK ABOVE FOR DUES AMOUNT) Active member ,   Associate member ,  Retired member ,  Honorary member Student member**
** Student applicant's anticipated date of graduation: Please use mm/yy format
Dues amount*:   Please enter amount in following format: $x.xx (As calculated by you based on membership type and date of application). Student applicant enter 0.00
CLE Scholars Club purchase:  By checking this space I am purchasing the unlimited live CLE Scholars Club Program that is good through May 31st. Please add $249 to total.
Optional - I wish to support the SCBA and become a Sustaining Member for an additional $150.00* Yes , No
I wish to enroll in automatic recurring annual dues payment Yes , No
Voluntary Contributions Suffolk Academy of Law     ,    Development Fund     ,    Pro Bono Foundation     ,

Lawyer Assistance Foundation     ,     SCBA Charity Foundation     ,     Scholarship Fund


The Total Amount Due*: Please add you Dues amount, CLE Bundle amount (if any), Sustaining Member amount (if any), and Voluntary Contributions amount (if any) and enter the total in this box in following format: $x.xx Student applicant enter 0.00
Method of payment:

Credit Card information:

Charge card type* (choose one):

American Express (AMEX) ,    Master Charge ,     Visa ,    Discover , STUDENT APPLICANT

Account # *            Expiration* : (Please use mm/yy format)    CVV2*

I hereby authorize the Suffolk County Bar Association to charge the above total to my credit card account *:

** Student applicants must provide an enrollment verification letter from their educational institution via e-mail or facsimile

Student applicants should enter "00/00/00" for their date of admission, and "n/a" as their response to State and Department of admission. For Credit Card, Choose STUDENT APPLICANT, for Account type "NONE" and for Expiration enter 00/00. For CVV2, enter "000"

How to Submit this form:

You may submit this form by clicking on the "submit" button below, you will rec.

You may submit this form by faxing the completed form (all required fields must be filled in) to: (631) 234-5899.

You may not mail this form!

$15.00 of your dues is applied toward your one year subscription to The Suffolk Lawyer.

Membership dues in the SCBA and LRIS fees are not deductible as a charitable contribution for Federal Income Tax purposes. However, such dues or fees may be deductible as a business expense.

For other questions or information you may call the Suffolk County Bar Association at (631) 234-5511 ext.221 or you may e-mail your questions to


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