NAWCC Lifetime Membership Application

Print and Mail to: NAWCC, Inc., 514 Poplar St., Columbia, PA 17512

I fully understand this Lifetime Membership policy and wish to apply for:

Circle One:
Regular Lifetime Membership	Associate Lifetime Membership
Regular Member joining as a Lifetime Member: Under age 40: $3,000.00 Age 40 and over: $2,000.00	Associate Member joining as a Lifetime Member: Under age 40: $1,500.00 Age 40 and over: $1,000.00

Signature: __________________________________________________________ Date: ________________

LIFETIME MEMBER APPLICANT INFORMATION:

Name (First, Middle, Last) ______________________________________________________________________

NAWCC Membership # ____________________

Address: ___________________________________________________________________________________

City _______________________________State ______________________ Zip+4_______________________

Date of Birth (Mo./Day/Yr.) ____/____/____ E-mail Address ______________________________________

Telephone Number: Home (_____) ______-_______ Work (_____) ______-________

Amount of Payment $ __________________ Date of Payment ____/____/____

Circle One: Check enclosed VISA MasterCard Discover American Express

Card Number _____________________________ Exp. Date _____________________

Cardholder’s name _____________________________________ CVV Code___________________

NOTE: If this membership is being gifted to another person and/or cardholder’s name is different from the member, the cardholder’s correct billing address must be shown in the space below. The recipient also must already hold a current NAWCC regular or associate membership as appropriate.

Donor billing information:

Name as appears on Credit Card Billing Address _____________________________________________________

City _________________________ State __________________________Zip+_______________