| Date of Request *: |
Please use mm/dd/yy format |
| Name*: |
|
| Firm: |
|
| 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*:
|
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
TOTAL AMOUNT OF VOLUNTARY CONTRIBUTION - |
| 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
membership@scba.org. |
|
|
Disclaimer / Privacy & Security / Accessibility
|
