Personal Information
Name:_____________________________________
Address:____________________________________
City:______________________________
State:____________ Zip:_______
Daytime Phone:____________________ Evening
Phone:__________________
Date of Birth:__________________
Council
Requested:______________________________________________
(Please use the Council Code: HAMPRD
for membership in the Hampton Roads Council.)
Sponsor Requested
(optional):_________________________ Number:______________
Membership Type (Please Check
One)
Regular One Year
Membership -- $40.00
Regular One Year
Membership for an Active Duty Spouse -- $30.00
Two Year Membership -- $75.00
Three Year Membership -- $100.00
Husband / Wife Membership
-- $70.00
Life Membership -- $450
Husband / Wife Lifetime Membership -- $650.00
Community Affiliate ( Business ) -- $400.00
Method of Payment
(Please
Check One)
Check
Enclosed VISA MasterCard
For Credit Card Payments:
Credit Card Number:
__________________________ Expiration Date:________
Your Signature:_____________________________________________