Club name:
Primary contact: Email:  
Secondary Contact: Email:  

Address:

City: State/Prov: Zip/Postal:
Website:  

Meeting date/time:
Location:

At least 5 club members must be (or become) SSMA members.  If individuals have applied, but not received confirmation, please state 'applied' in the SSMA block.

When submitted, this form will generate an email to the Membership Director who will process your application.