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FEDERATION MEMBERSHIP FORM
To join the Federation, and/or order our products, please print out and complete this form.
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I would like a trial membership for one year for only $45 - Foreign $55. |
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$ _________ |
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I would like to become a Silver Founder for $90 - Foreign $110. (Inludes a silver tone membership card, all member advantages for TWO years and a frameable individual silver tone certificate) |
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$_________ |
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I would like to become a Gold Founder for $700 - Foreign $900. (Includes an engraved gold tone membership card, all membership advantages for LIFE and an engraved gold tone plaque.) |
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$_________ |
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In addition to the above, I would like to contribute the following amount to the Federation's efforts. |
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$_________ |
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TOTAL |
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$_________ |
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DESCRIPTION |
Size/Color/... |
PRICE |
TOTAL |
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| Please specify applicable options (size/color/state/binding/etc.) in space provided. | ||||
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SUB TOTAL . . . |
$___________ | |
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TOTAL SHIPPING CHARGE . . . |
$___________ | |
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TOTAL . . . |
$___________ | |
Name_________________________________________ Address___________________________________
City/State/Zip____________________________________________________________________________
Country__________________________________________________________________________________
Day Phone_________________________________ Eve. Phone_____________________________________
E-Mail Address____________________________________________________________________________
Method of Payment: ____ Check Enclosed_____Credit Card
If you are paying by check, please make it payable to: National Historic Route 66 Federation
If you are paying by credit card, please fill in the following information:
_____VISA _____MASTER CARD _____DISCOVER _____AMEX
Card No.__________________________________Exp. Date_______ Signature__________________________