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Member #1 Name 
Member #2 Name
Birth Date
Birth Date
Street Address 
City
State
Zip Code
Please let us know if you have Questions or Comments or additional information
format:  mm/dd/yyyy
TM
Second member at same address
(Membership fee is per person, not per household)
Online Membership Application
Primary phone
Secondary phone
Email address
format:  mm/dd/yyyy
Select type of application:
     Notes re PayPal:
  • you do not need a PayPal account to pay this way
  • the PayPal payment page will reference your "donation" but our records will clearly indicate a membership payment (it's a long story...)
($50 per person, $100 if two names entered above) Membership fee is non-refundable
($25 per person, $50 for two). 
Please send Newsletter via:
Please contact via:
Information Delivery
NEXT of KIN information: It is important to include the name of the person who may be handling your affairs. 
(you should let this person know you are listing him/her in this capacity)
Full Name
Relationship
Street Address 
City
State
Zip Code
Telephone
Email address
Check out our Member Benefits!
Please indicate under Comments (below), the name of the chapter you are transferring from, and your member number at that chapter.
MEMBER information
I am applying for membership for:
-- enter your own (& spouse's) name in MEMBER info. 
​-- enter THEIR name in MEMBER info, and your own info as next-of-kin
-- to help encourage planning for the inevitable.  Enter your own  contact information as                NEXT of  KIN or in the Questions/Comments section below.  Include your email address.
Name and city of hospice, hospital, or nursing home (for at-need memberships)
Tell us how you found out about us. 
Check as many as apply.
Email ONLYPostal mailNone
Email Postal mailPhoneNext-of-kinNone
New Membership
Transfer Membership
Myself (/ and spouse)
A friend or family member near death
This is a Gift Membership
Relative/Friend
Hospital, hospice, nursing home, etc
Event, Presentation
Brochure, Literature
Web search
Other