Membership Application

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Prefix: First Name: Middle Initial: Last Name: Suffix: Organization: Job title: Email: Primary phone (cell preferred): Evening phone: Address Line 1 Address Line 2 Address Line 3 City: State: County or Province (Foreign) Zip or Postcode: - Country: Birth Date: / / Gender Web Site: Membership:

Individual - Annual Plan, Paid Monthly ($8 pm)

Individual - Annual Plan, Paid in full ($86.40 pa incl 10% discount)

Family/Household - Annual Plan, Paid Monthly ($10 pm)

Family/Household - Annual Plan, Paid in full ($108 pa incl 10% discount)

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The Britsburgh Team