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)*

E-mail Address:*

Website:

Facebook

Instagram

Offers Virtual Lectures/Workshops (Use dropdown to indicate Yes/No)*

Lectures

Workshops

Shop Information

Other business information

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*

| | | | | | |