SAMA Membership Application - Allied Individual

An Allied Individual member of SAMA works professionally in a related field

and is interested in intentional music or sound practices.

Date of application:

Name of applicant:

Mailing address:

Email address:

Website:

Personal phone:

Office phone:

3 Yes 3 No This application is being submitted as part of an Allied Organization Membership application.

Name of the organization:

Current professional identity:

(Example: nurse, occupational therapist, educator, musician, author, etc).

Please describe how you are involved with/use intentional sound and music in your work.

Please indicate if you have the following:

Academic degrees or certifications. Please list your granting institutions or schools.
Please provide a reference for any certificates.
3

3 Professional license. Please include a copy of your current license.

SAMA Allied Ind App/101101 page 1 of 3

Has a professional license or certification that you have earned ever been challenged, suspended or revoked?

3 Yes 3 No

If “Yes” please explain:

Statement of Agreement
My Application
•
By signing below, I verify that the statements that I have made on this application are all true.
• I understand that SAMA may request more information as needed to complete the application process. I recognize that
completing an application is no guarantee of acceptance.
Ethics
• I have read and understand the SAMA Code of Ethics. As a member of SAMA, I agree to fully uphold and abide by all
sections of the Code: the Preamble, Mission Statement, General Principles and Ethical Standards.
• As a member of SAMA, I support the use of use SAMA policies and procedures to help resolve code of ethics
related issues.
• I understand that SAMA service or trademarks, logo or membership materials may only be used by, and/or considered valid
for, Professional Members in good standing.
Authorization Release
•I understand that the information I have provided SAMA may be verified by contacting persons and organizations whom
I have listed on my application. I agree to release from liability and damages SAMA and its agent(s) who conduct such
verifications, as well as any individual or organization which I have listed on my application. I understand that the
completed document will be kept in SAMA confidential files. The information supplied will be seen only by the review
committee and if requested, myself.

Signed Date

Payment
Check any that apply. Further information can be found at SoundAndMusicAlliance.org

1. 3 $100 - Allied Individual Member annual fee

3. $ Charter Campaign contribution ($250, $500, $1,000, $5,000)

(Includes complimentary or reduced memberships for qualified applicants. See Charter Campaign page.)
3
The $250 opportunity ends December 31, 2010.

4. 3 $ Helen Bonny Scholarship Fund (Donations of any size are welcome.)

5. 3 $ Total due

SAMA Allied Ind App/101101 page 2 of 3

 Method of Payment
SAMA accepts checks and credit cards.

3 Payment by check – Make checks payable to Sound and Music Alliance

Check enclosed for a total of $

3 Payment by credit/debit card (VISA/MC only)

Credit/debit card total of $

Name as it appears on the card:

Type of credit card (MC/VISA) Credit card #

Exp date Security code (3 digits)

Billing address (if different from the address on page 1)

Signed Date

Submission Instructions
Please make sure that you have included:
1. 3 A completed application
2. 3 Payment (check or credit card)
3. All documents relevant to your application:
•
3
Copies of certificates or licenses, etc.

Send your completed application and payment to:

SAMA
PO Box 127
Hillsdale, NY 12529 USA
Tel: 518-325-5546
Email: applications@SoundAndMusicAlliance.org

Notification
Thank you for your application. You will receive an email from SAMA within a week
of receipt of your application with notification of the approximate processing date.

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