Membership Registration 2016 – 2017 Membership Application (pdf version) School Name School type Individual SchoolHome SchoolSchools sharing one principalCommunity GroupsCollege Grade Levels (Ex. K-6, 6-8, K-12) Membership # optional Is it an additional membership? Is this a residence address? Shipping Address for membership package, please use street address for UPS delivery. Street Street 2 District County City, State, Zip , , Please use state abbreviation. ( e.g. NY, PA ) Country Do you want to purchase an additional membership such as Team B, Team C ?No12345678910 Mailing Information for Newsletter First Name Last Name Day time phone# Home Phone Fax Email Street Street 2 City, State, Zip , , Please use state abbreviation. ( e.g. NY, PA ) Country Total Credit Card Type VISAMASTERDISCOVERAMERICAN EXPRESS Credit Card Number CVV code What is the CVV Code? Expiration Date MM123456789101112/YYYY20142015201620172018201920202021202220232024 Card Holder Name Items in BOLD are required fields.