Renewal and Consent Form

KSEA Membership Renewal and Consent Form

Fill out the form carefully to allow HQ renew your membership on your behalf
Member Name*

First NameMiddle NameLast Name
Member E-mail (This can be found if you log into our website: KSEA)*
I won't be able to renew your membership if I cannot find your account
Member Login ID (This can be found if you log into our website: KSEA)*
I won't be able to renew your membership if I cannot find your account
Local Chapter you would like to renew your membership under*
Member Type*

Regular ($35)Graduate Student ($15)Undergraduate Student ($0)
Affiliation Name *
i.e. University of ______
Payment Option:

through my local chapter

For Undergraduates:

Please stop filling out this form and renew your membership directly at: https://www.ksea.org/signIn?next=profile
Membership Options
prevnext( X )
Regular MembershipOne Time Purchase ($35/YR)
$35.00

Graduate Student MembershipOne Time Purchase ($15/YR)
$15.00

Total

$0.00
For Regular or Graduate Student Membership Purchase:

You're welcome to renew your membership directly at our website for higher security, but feel free to provide the below information here. To renew at our website, please visit here: https://www.ksea.org/signIn?next=profile
Billing Address - Zip Code*
XXXXX

By checking the box below, I, {memberName}, authorize KSEA to use the information on this form to pay the membership dues for the upcoming membership term. I understand that the payment will be processed automatically for me.

If there is an active membership at the moment or the name/email does not match with KSEA DB, I understand that it may not be processed.

I acknowledge that the local chapter I chose on this form is the same local chapter I set up on KSEA Profile Page. If it doesn't match, I understand this request may not be processed.
Consent and Authorization*

Agree to the terms and authorize the membership renewal/purchase and payment.
Should be Empty:

KSEA Membership Renewal and Consent Form