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Credit Card Payment Form

(Visa / MasterCard ONLY)

2012 DUES ARE NOW BEING COLLECTED
Please fill out the following information and press the SUBMIT button. If you do not feel safe submitting your Credit Card information over the Internet (quickest method), please feel free to down load a copy of the form, fill it out, and mail it in, or send it as an E-Mail attachment to the address on the form. You may down load the form from the link at the bottom of this page or from the main page.

All fields with an asterisk (*) behind them require input in order to successfully complete the form.







Payment Type/Amount *	Select Regular Membership ($50.00 Per Person) Vendor Membership ($50.00 Per Person) Vendor Web Site Donation ($100.00) 1 Vendor Membership & Web Site Donation ($150.00) Training Session March 6-7-8 2006 ($395.00) Other (amount & explanation in comments) Training Session (Other - put Date In Remarks) Form Test (Officers Only)
Dues Year/Period	2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Your Name *
Your Company
Address *
Address Line 2
City *
State *	Select Non-USA Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississppi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Country *	Select United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territories Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People's Republic of Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories FYROM Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island And Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao Peoples Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and Sandwich Islands Spain Sri Lanka SudanSuriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Your Telephone
Your FAX
Web Site Address
Your E-mail *	(For Verification)
Type of Company *	Select Electricity Gas Cable TV Water Electricity and Gas Electricity and Water Electricity, Gas and Water Gas and Water Utility Vendor Public Utility Commission State/Local Building Department State/Local Law Enforcement Federal Law Enforcement State/Local Fire Department Other (explain in comments)
Credit Card Information:
Name As On Card *
Billing Address *
Billing City *
Billing Zip Code *
Card Type *	Select Visa MasterCard (Visa or MasterCard ONLY)
Card Number *	- - - (Example: 0101-0202-0303-0404)
CV2 Number *	(CV2)(3 Digit number from back of Card)
Expiration Date *	(MO/YR)
It is strongly suggested that Non United States applicants use the "Comments" area below to show us your mailing address EXACTLY as it should appear on an envelope, and/or for general comments from anyone about anything.

This area is also to be used to explain any and all payments other than the standard selections listed at the top.


Comments:

If You Left Any "Required" Fields Blank, Back Up, Correct and Resubmit.

After clicking "Submit", Please Wait While Your Data Is Posted!







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SIGN-UP.EXE is "Self Extracting Zip" containing copies, in several formats, of the Membership form that can be used to sign up and pay by credit card and/or check. The form may be sent via land mail, or by FAX, and E-Mail with Credit Card info (sent to the E-Mail address on the form).

SIGN-UP.ZIP is a "Zip" file (the same one as above), but is NOT self extracting; you need software to un-zip it. It contains copies, in several formats, of the Membership form that can be used to sign up and pay by credit card and/or check. The form may be sent via land mail, or by FAX, and E-Mail with Credit Card info (sent to the E-Mail address on the form).

CCSIGNUP.DOC is copy of the Membership form that can be used to sign up and pay by credit card (can also be mailed with a check). The form may be sent via land mail, FAX, or as an E-Mail attachment, sent to the E-Mail address on the form. It is in Microsoft Word '97 format.

CCSIGNUP.RTF is copy of the Membership form that can be used to sign up and pay by credit card (can also be mailed with a check). The form may be sent via land mail, FAX, or as an E-Mail attachment, sent to the E-Mail address on the form. It is in "Rich Text Format".





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