Scan Membership Form

	Membership Form Annual Dues June 1 through May 31

Name. Street. City.... State.. Zip Phone Email.
Membership type
Individual ............................. $20.............. $ ___________________________________________ Student ............................... $10.............. $ ___________________________________________ Family ................................. $30.............. $ ___________________________________________ Patron ................................. $50.............. $ ___________________________________________ Life ...................................... $250............ $ ___________________________________________
Other contributions
Laurence Newquist Student Scholarship Awards/prizes		$ ___________________________________________ $ ___________________________________________
TOTAL ENCLOSED $ ___________________________________________
Please make checks payable to SCAN, Inc. and mail to: SCAN Membership Chair PO Box 41 Newtown, CT 06470
Please check the activities or committees you are willing to help with
Hospitality Show receiving Show sitting		Publicity Membership Demonstrating
Other (please specify) ______________________________________________________