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First Name		Last Name
Street Address		City
State	- - Choose One - - - - US States - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY - - Canada Provinces - - AB BC MB NB NL NT NS NU ON PE QC SK YT	Zip Code
Date of Birth ( xx/xx/xx)		Type of membership	Regular Membership $20 (1yr) Junior Membership (under18) $10 (1yr) min age 12 U.S. Military (active duty - $15 - 1yr) Standard "Lifetime" Membership $300 Senior "Lifetime" Membership (65 or over) $175)
Is this a renewal?	No it's a new membership Yes I'm renewing my membership	Phone
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Referred By		Payment Method	- choose from list - Master Card / Visa through PayPal, please send a invoice PayPal to ciminodw@gmail.com Snail Mail
Please enclose additional window stickers at $3 each		Please send invoice
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