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Membership Application

Please complete each of the sections below, then click NEXT. Required fields are noted by an asterisk*.

Eligibility Criteria
Person who is employed by a corporation and who is engaged in a shareholder services function. Person who individually or through a firm provides shareholder services to a corporation, such as the transfer of securities, proxy solicitation, locating lost shareholders, financial printing, etc.

Membership Annual Rate - $495 Term of Membership - October 1 through September 30

Mid-Year Discounted Rate - $375 Term of Membership - On/after April 1 through September 30

Individual Member Data

Member Type*

First Name*	Middle Initial	Last Name*

Title	Company Name*	URL

Address*	City*	State/Prov* Postal Code*

Business Phone* Business Fax	Email*	Cell Phone

Company Data*

Service Provider Business Sector

Issuer Business Sector

For Issuers Only

Incorporation*

Exchange*

Ticker Symbol

Transfer Agent Type*
Agent Name*

Issuer Reporting Structure

Recent Experience With?
(Choose all that apply)

If In-house,
Software Used?

423 Plan	Acquisition	DRIP/Direct Purchase
ESOP	Exchange	Insider Reporting
Merger	Odd Lot	Restricted Stock
Reverse Split	Spinoff	Stock Options
Stock Split

Association Data

How did you hear about SSA

Years in
shareholder services

Check eLearning Courses Taken

Attend Last Year's Conference?

Introduction to Shareholder Services

Unclaimed Property Processing

Want To Get Involved in SSA? Indicate your areas of interest and we will contact you!

Annual Conference	Growing SSA	Legislative & Regulatory	Member Education
Monthly Meetings	Web Site

I hereby apply for membership in the Shareholder Services Association and certify that I meet the eligibility criteria for membership.

Questions? Jane Keister, Membership Chair jkeister@standard.com

This website is provided solely for the benefit of the CTA's members and is intended for informational purposes only.
Liability arising from reliance upon any article or statement contained herein which may prove to be inaccurate or incomplete is specifically disclaimed.