Earth's Common Sense Printable Membership Form (on-line form)

Date:_________________

   

Simply print this form using your Browser's Print Feature. Completely fill out the form.
Mail your completed membership form along with check or money order to:

Earth's Common Sense Think Tank
P.O. Box 607
New York, NY 10021-0013

Member Information
First Name: ________________________________________________________________________________________________________
Last Name: ________________________________________________________________________________________________________
Street Address: ________________________________________________________________________________________________________
City: ___________________________________________ State/Province:_____________________________
Zip/Postal Code: ___________________________________________ Country: ___________________________________
Work Phone: ___________________________________________ Home Phone:_______________________________
E-Mail: ________________________________________________________________________________________________________

Please provide the following member information
Qty.
No. of Years Membership Description Membership Fee Total Membership Fee
_____ ________
Supporting Friend of Humanity & Democracy
 $365 A Year ___________
_____ ________
Individual Friend of Humanity & Democracy
 $155 A Year ___________
_____ ________
Household For 2 Friends of Humanity & Democracy
 $255 A Year ___________
_____ ________
Low Income For 2 Friends of Humanity & Democracy
 $155 A Year ___________
_____ ________
Student Supporting Friend of Humanity & Democracy
$55 A Year ___________
     
TOTAL
 $_______________

Member Billing Information
Credit Card:
VISA, --- MASTER-CARD, --- AMERICAN EXPRESS - (Circle One)

Cardholder Name:

_____________________________________________________________________________________________________

Card Number:

_____________________________________________________________________________________________________

Expiration Date:

_____________________________________________________________________________________________________
Street Address: _____________________________________________________________________________________________________
City: ______________________________________ State/Province: __________________________________
Zip/Postal Code: ______________________________________ Country: ________________________________________


Comments or special instructions for printable membership form

1) - Print this form using your Browser's Print Feature.

2) - Fill the form out completely.

3) - Mail the form to - Earth's Common Sense Think Tank - P.O. Box 607 - New York, NY 10021-0013

4) - If you are paying by check or money order, make your check or money order to: Earth's Common Sense Think Tank.

Thank You For Becoming Earth's Common Sense Think Tank Member.