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SIMIAN SOCIETY OF AMERICA APPLICATION FOR MEMBERSHIP / RENEWAL

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NAME *

ADDRESS: *

PHONE: *

E-mail address: *

PLEASE LIST ONE REFERENCES THAT IS A CURRENT SSA MEMBER *

PLEASE LIST PRIMATES IN YOUR CARE: *

SPECIES, NAME, AGE, SEX *

ARE YOU AFFILIATED WITH ANY ORGANIZATION THAT IS WORKING TO CREATE BANS OF PRIVATE PRIMATE OWNERSHIP? *

PLEASE LIST YOUR VET: *

DO YOU CONSENT TO THE USE OF SOCIAL MEDIA PICTURES FOR OUR MAGAZINE AND WEBSITE? *

INDIVIDUAL MEMBERSHIP $40 / SPOUSE OR LIFE PARTNER $10

LIFE MEMBERSHIP $750 MAY NOT BE TRANSFERRED

ACTIVE MEMBERSHIP (AVAILABLE TO THOSE WHO OWN OR HAVE PREVIOUSLY OWNED NON HUMAN PRIMATES)

ASSOCIATE MEMBERSHIP (AVAILABLE TO THOSE WHO DO NOT OWN A NON HUMAN PRIMATE BUT HAVE AN INTEREST IN PRIMATES AND WISH TO SUPPORT THE ORGANIZATION AND ITS PURPOSE AND OBJECTIVES)

DO YOU CURRENTLY OWN AND CARE FOR NON HUMAN PRIMATES?

HAVE YOU PREVIOUSLY OWNED AND CARED FOR A NON HUMAN PRIMATE?

PLEASE CHOOSE TYPE OR MEMBERSHIP (INDIVIDUAL OR LIFE): *

PLEASE CHOOSE ACTIVE OR ASSOCIATE MEMBERSHIP: *

MAKE YOUR PAYMENT VIA PAYPAL: simiansociety1957@gmail.com PLEASE ADD $2 IF PAYING VIA PAYPAL *

PLEASE CONSIDER DONATING TO ONE OF OUR FUNDS: PRIMATE HEALTH NETWORK, LU HALL PRIMATE PLACEMENT $_____

DONATIONS TO GENERAL FUND, EDUCATION, LEGISLATION, PUBLICATIONS $_____

DONATION IN HONOR OR MEMORY OF $ ________

Captcha (spam protection code) *

SUBMISSION OF THIS FORM IS DECLARATION THAT ALL THE INFORMATION ON THIS APPLICATION IS CORRECT AND HAS BEEN ANSWERED TRUTHFULLY. I UNDERSTAND THAT THE SIMIAN SOCIETY OF AMERICA RESERVES THE RIGHT TO REFUSE OR REVOKE ANY MEMBERSHIP, AT ANY TIME, ACCORDING TO THE BYLAWS. CHECKS MAY BE MADE PAYABLE TO: SIMIAN SOCIETY OF AMERICA MAIL TO: DEBBIE RIGA 611 KINGSMOOR DRIVE SIMPSONVILLE, SC 29681

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