Name: New Member Renewing Member

Current Address: City: Zip code:

Phone number: E-mail address:

Expected Graduation Date: College/University:

I hereby affirm that I am a full time student (minimum 12 hours) and authorize verification of my student status from my departmental chair.

Signature of Dept. Chair ________________________________________ Date ____________

If a new member, who referred you to SHAWNY:  ____________________________

Benefits of membership include: Newsletters providing information about area workshops, seminars, eligibility for annual SHAWNY scholarships, and networking with area professionals/students from other programs and more!

Print out completed application and send it along with $15 check made payable to SHAWNY to:

SHAWNY Membership Chair:
Donna M. Ringholz
267 McNaughton Ave.
Cheektowaga, NY 14225

OFFICE USE ONLY: Date rec'd: amt.: check #: input on db: