New Customer Registration Form

Member or Representative Full Name *

First Name Last Name

Organization/Company

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

E-mail *

example@example.com

Organization or Company website address

Is this a renewal?

yes no

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State Membership Each applicant for State Membership shall be the state agency or agencies designated by a State to administer and manage its motorcycle safety program or components of that State's program. State Members shall designate an individual to serve as its SMSA representative for the purpose of receiving notices and otherwise acting on behalf of the State Member in the conduct of SMSA business

$ 1,200.00

SMSA Silver Level Individual Membership Each applicant for Individual Member shall be an individual actively involved in supporting the reduction of injuries and fatalities associated with motorcycle crashes and promote responsible motorcycle operation. Benefits include the opportunity to shape the future of our profession by participating in SMSA programs and network and share ideas through meetings and annual Symposiums. Receive SMSA materials, including our Quarterly eMagazine, Special Reports, and Strategic Plan. Member rates for conference registration.

$ 25.00

SMSA Gold Level Individual Membership Upgrade to Gold for added benefits of the opportunity to serve on SMSA Committees or the SMSA Executive Committee and gain access to the SMSA Listserv.

$ 50.00

Supporting Corporate Partner An incorporated business or an organization that actively and continuously supports the reduction of injuries and fatalities associated with motorcycle crashes and promote responsible motorcycle operation. Each Supporting Member shall designate an individual to serve as its SMSA contact for the purpose of receiving notices and otherwise acting on behalf of the Supporting Member. Membership includes two free exhibit spaces for the Annual Conference, two free registrations for the Annual Conference., four free ads in the SMSA Spotlight Magazine, conference program agenda or website annually, Opportunity to serve on the SMSA Executive Committee, Use of the SMSA Proud Partner Logo.

$ 2,500.00

Supporting Corporate Member An incorporated business or an organization that actively and continuously supports the reduction of injuries and fatalities associated with motorcycle crashes and promote responsible motorcycle operation. Membership includes one free exhibit space for the Annual Conference, two free ads in the SMSA Spotlight Magazine, conference program agenda or website annually, opportunity to serve on the SMSA Executive Committee and use of the SMSA Proud Supporter logo. Each Supporting Member shall designate an individual to serve as its SMSA contact for the purpose of receiving notices and otherwise acting on behalf of the Supporting Member.

$ 1,200.00

Supporting Non-Profit Member A national non-profit organization or association, or non-profit educational institution or federal government in the field of motorcycle safety. Membership includes one half-price exhibit space for the Annual Conference and the use of the SMSA Proud Supporter logo

$ 600.00

Supporting Small Business Member A small business with less than ten (10) employees in the field of motorcycle safety. Membership includes one half-price exhibit space for the Annual Conference and the use of the SMSA Proud Supporter logo

$ 600.00

Total

$ 0.00

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