Checkout - Order Information

Has the application for membership been completed?:

Club Name *: *

District *: *

Zone *: *

Club ID Number *: *

Submitted By:

Full Name *

First Name *

Last Name *

Title:

Home Phone Number *

Area Code *

Phone Number *

Alternate Phone Number

Area Code

Phone Number

E-mail *: *

New Member Info:

Registration and Badges

New Member Registration: $15.00 (mandatory for all new members and reinstatements after 5 years)

Price includes new member registration and a standard name badge (shipping and taxes included)

Type of Badge * Standard Name Badge
Magnet $3.50 + taxes (when applicable)

Customize badge

Name to put on badge (if different then above):

First Name

Last Name

Please indicate any additional comments, questions or requests:

Billing Info

E-mail *: *

First Name *: *

Last Name *: *

Company:

Address Line 1 *: *

Address Line 2:

City *: *

State/Province: *

Country *: *

Postal/Zip Code *: *

Phone Number *: *

Payment Method

I wish to pay by

Checkout - Order Information

New Member Registration Form

Submitted By:

Full Name *

Home Phone Number *

Alternate Phone Number

New Member Info:

Full Name *

Home Phone Number *

Business Phone Number

Cell Phone Number

Fax Number

Sponsored by:

Spouse/Partner Name:

Registration and Badges

Name to put on badge (if different then above):

Billing Info

Payment Method