Membership Application

Basic Membership Free Voluntary Contribution (Please enter a minimum amount of $0 up to $98.00) Supporting Member $ 99.00 Annually Sponsoring Member $ 199.00 Annually Your name: Your email address: Address: City: Zip State Your phone number: ______________________________________________________________________ Credit Card Information   (for paid memberships and contributions only) Master Card Visa Card American Express Discover Card Name on card: Security code: Card number: Exp. date Billing address: State Phone Zip City _______________________________________________________________________ Daily Smoker   Social Smoker Occasional Smoker Non- Smoker Former Smoker Are you a: (check all that apply) Do you prefer? Are you interested in volunteering for the coalition? Are you a business owner affected by the smoking ban? Would you like to advertise or offer your products/services to members of the Coalition? How did you hear about our site? Cigars Cigarettes Both Neither Yes No Yes No Yes No Comments: I certify that I am above the age of 18 and I have read and agree to the privacy policy

Click Here to Use   Our Secure Form

© Copyright 2005 socialsmokers.org