MEMBERSHIP APPLICATION
Date _______________ [_] New Membership [_] Renewal [_] Contribution
[_] Regular membership $75.00 per year
[_] Patron membership $150.00 or more per year
[_] Life Membership $750.00 in one year Amount Enclosed $______________
Please make check or money order payable to "FACE" or use your credit card
FACE is unable to accept credit card payments at this time.
[_] Visa [_] MC [_] AMEX
Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Expiration date (Month/Year): |__|__|/|__|__|__|__|
Signature (for credit card): __________________________________________Name: _________________________________________________________
Address: ________________________________________________________
_______________________________________________________________
City: __________________________ State: ________ Zip: ________________
Residence County: ________________________________________________
Your Date of Birth: ____________________________
Phones:
[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________
[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________
[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________
[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________
Email address: ___________________________________________________
Social networking sites (MySpace, FaceBook, Twitter, LinkedIn, etc.):
________________________________________________________________
Are you registered to vote? [_] Yes [_] No
If not registered, are you eligible to vote? [_] Yes [_] No [_] I don't know.
[_] FACE may use my name as a supporter for legislative purposes. (PLEASE CHECK)
How did you learn of FACE? __________________________________________
________________________________________________________________
I have _____ child(ren). My youngest child's date of birth is: _____/_____/_______
How many overnights per month do your children spend with you? _____________
Jurisdiction of my case is: County: _____________________ State: ___________
Judge(s) with whom I have had personal experience include:
Judge: ____________________________ County: ________________________
Judge: ____________________________ County: ________________________
Judge: ____________________________ County: ________________________
Lawyers with whom I have had personal experience include:
Name: ____________________________ City & State: _____________________
Name: ____________________________ City & State: _____________________
Name: ____________________________ City & State: _____________________
Mental health professionals with whom I have had personal experience include:
Name: ____________________________ City & State: _____________________
Name: ____________________________ City & State: _____________________
Name: ____________________________ City & State: _____________________
Please print, fill out and mail this application with your check or money order to:
FACE
P.O. Box 3302
Cherry Hill, NJ 08034
FACE is unable to accept credit card payments at this time.