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Gender *	Male Female
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Please indicate the duration/type of membership

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Life ( Duration:Life | Amount: $ 500.00)
Patron ( Duration:Life | Amount: $ 1000.00)
Primary ( Duration:Yearly | Amount: $ 25.00)
Primary ( Duration:5 Years | Amount: $ 100.00)
Primary ( Duration:3 Years | Amount: $ 70.00)

Please provide information about the member if different from above

First Name
Middle Name
Last Name
Gender	Male Female
Spouse Name
Address
City
State
Zip Code
Country (if other than USA)
Phone
Office Phone
Cell Phone
Email