EmailMeForm
AVCA -MIVCA Affiliate Partner Membership Form
*-Required
*
New Membership
Membership Renewal
Name
*
First
Last
Coaching/Job Title
*
Email Address
*
School/Organization
*
School Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Phone
*
###
-
###
-
####
Mobile Phone
###
-
###
-
####
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Please mail my publications to:
*
School Address
Home Address
*
High School/Interscholastic Membership - $75.00
*
PAY BY CHECK (Payable to "AVCA"; Mail to: AVCA, 2365 Harrodsburg Rd, Suite A325, Lexington KY 40504-reCAPTCHA-CLICK SUBMIT)
PAY BY CREDIT CARD (Input CC information below-reCAPTCHA-CLICK SUBMIT)
If Paying by Credit Card; What Type of Card?
VISA
MASTERCARD
AMEX
DISCOVER
Credit Card**
Card Number
Expiration
MM
/
YY
CVV
What is this?
3 or 4 digit number printed on the back/front of your credit card
Protected in vault
Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
**YOU WILL BE RE-DIRECTED TO PAYPAL TO COMPLETE TRANSACTION. DISREGARD IF PAYING BY CHECK.
(IT WILL REQUIRE INPUTTING YOUR CREDIT CARD INFORMATION AGAIN. YOU WILL NOT BE CHARGED TWICE.)
