Current Member Number
( Enter your member number if you are updating your registration.)

Your Full Name:

Your Nickname or name you want on the Badge
  
                                 This will be the name listed on your New Registry Name Badge

Full Names for additional badges :

Additional Badge #1:
 
Additional Badge #2:

Additional Badge #3:

Additional Badge #4:

(Please) Add $8.00 Per Additional Badge
EXAMPLE: New Badge plus 2 Additional = $24

Mailing Address:

City: State: Zip:

Country:

Day Phone: Evening Phone:

Fax:  E-Mail:*

*Please list your full E-Mail Address ie: JohnPublic@AOL.com   if it's not listed,
we cannot respond to your registration. Thanks!