Simian Society of America, Inc.

Simian Society of America, Inc.

Providing Information for a Lifetime of Care

Join

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Nonhuman Primate Help:

573-701-3282

816-246-1960

870-838-5710

SIMIAN SOCIETY OF AMERICA, INC.

Application for Membership

I wish to make application for membership in The Simian Society of America.

____ New _____Renewal

______ Active Membership [Available to those who currently own or previously owned and care for nonhuman primates at the discretion of the Board.] (“Caring” shall be defined as providing housing on your premises, feeding, maintenance, and veterinary care of captive non-human primates.)

______ Associate Membership [Available to those who do not currently own and care for a nonhuman primate at their premises but have an interest in nonhuman primates and wish to support the organization and its purposes and objectives at the discretion of the Board.]

Classes of Membership:

Individual $40.00

Spouse $10.00 (Same address/no publication. May be purchased only in conjunction with an individual active membership. Husband, wife or life-partner ONLY)

Life* (active membership only) $750.00

(*Life memberships may not be transferred to another person and are non-refundable.)

Membership is renewed each July. New members joining January – June, pay for a full year PLUS the prorated amount of the remainder of the year.

Contact the Membership Chairman for the total due. The Membership Chairman can be reached at brenkel@aol.com or by phone 816-246-1960 or 816-540-3031.

OUTSIDE USA: Please add $25.00 Canadian, $45.00 foreign mailing. Dues must be in USA currency.

Allow four to six weeks for first delivery.

All dues and foreign postage are prorated to renew each July. Contact Brenda Keller for amount due.

Additional donations may be made to the following funds:

$________ PHN (Primate Health Network) $________ LHPP (Lu Hall Primate Placement)

$________ Legislation

$_________ General Fund

$________ Education Department

$_________ Publications

$________ In Honor or Memory of________________

PLEASE PRINT CLEARLY. All information you provide will remain confidential.

NAME ____________________________________________

ADDRESS ____________________________________________

CITY ___________________________________ STATE ________ ZIP __________

PHONE (H) ______________________

(W) _________________ (C)___________________

FAX (H) _________________________

(W) ______________________________

EMAIL ADDRESS ____________________________________________

Occupation ____________________________________________

Designated Home Chapter _______ Member of other Chapters, which ones? ___________________

Reference #1/Reference #2

Name: ________________________________

Email: ________________________________

Phone: ________________________________

·Required to be considered for membership.

1.Do you currently own and care for nonhuman primates? (“Caring” shall be defined as providing housing on your premises, feeding, maintenance, and veterinary care of captive non-human primates.)

Yes No

Please list below the primates in your care (specific species, name, age, sex, year of birth, or approximate age if birth date unknown):

2.Have you previously owned and cared for or have a direct working relationship with a nonhuman primate? Yes No

Please explain in detail: ____________________________________________

* Applicants meeting one of these criteria may be issued an active membership at the discretion of the Board. Membership for this category will be reviewed each year.

Please list Name, Clinic name, Address and Phone Number, and email address of your Veterinarian that treats monkeys:

____________________________________________

Are you involved in or a member of, or affiliated with any individual, group, or organization that is working to create bans of private ownership of nonhuman primates?YesNo

If yes, please explain in detail:

____________________________________________

I declare that I have reviewed all information on this application and have answered all questions truthfully and correctly. I understand that the SSA reserves the right to refuse or revoke my membership at any time according to the bylaws. I have read and agree to the terms of membership.

Signed: __________________________________ date: _____________________

Please complete and mail with your check to:

SSA

Brenda Keller

16322 S Graham Rd

Pleasant Hill, Mo. 64080

Enclosed please find my check in the amount of $______________, payable to the Simian Society of America, Inc. Membership may be paid through PayPal. If using PayPal, there is a $2 processing fee.

Brenda Keller

816-540-3031

816-246-1960

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