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2022-23 Affiliate Membership Form
Affiliate Name*
DBA
Mailing Address:*
City, State, Zip*
Please publish my mailing address (Use dropdown to indicate Yes or No)*
Yes
No
E-mail Address:*
Website:
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Offers Virtual Lectures/Workshops (Use dropdown to indicate Yes/No)*
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Lectures
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2022-23 Annual Affiliate Dues $20 or $30 after Nov 30*
Check No., made payable to SCCQG:*
Date Check Mailed to Treasurer, SCCQG, 2329 Boone Ave., Venice CA 90291*
Repeat Email Address