* Required Information 
 * First Name: 

* Last Name: 

Affiliation or Additional Name: 
(Business, organization or 2nd person in same household) 

* Mailing Address: 

* City: 

State/Province: 

Zip/Postal Code: 

* Country: 

Telephone: 

Fax: 

E-Mail Address: 

* Select a Chapter: 

* Confidentiality: 
Member information appears in a published roster.
Select "No" to not have your phone, fax & e-mail address published.

* Membership Category

Yearly Dues

Select One

Regular 
(One or two people in same household)

$40

Commercial-Corporate 

$90

Sustaining 

$75

Sponsoring 

$150

Life, single 

$1000

Life, family 

Type the characters from the GREEN box.

Color Blind?