Date ____________    [] New Membership               [] Renewal      [] Contribution

Regular membership $75.00 per year       Patron membership $250.00 or more
Life Membership $750.00 in one year      Amount Enclosed $_____________
Please make check payable to FACE or use your credit card
[]Visa       [] MC      [] AMEX
Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Expiration date (Month/Year): |__|__|/|__|__|__|__|

Signature: _______________________________________________

Name _______________________________________________________
Address _____________________________________________________
____________________________________________________________
City _____________________________________
State ___________   Zip _____________________
Residence County ___________________________
Date of Birth _______________________________

Home Phone: ____________________      Work Phone:___________________________
Other Phone: ____________________      Email address __________________________

Are you registered to vote?  [] Yes    [] No
If not registered, are you eligible?   [] Yes    [] No   [] I don't know.
[] FACE may use my name as a supporter for legislative purposes (please check).
I have _____ child(ren),    youngest childs date of birth:__/__/__.
How many overnights per month do your children spend with you? ______
Jurisdiction of my case is __________________  County in the State of _____________.

Judge(s) with whom I have had personal experience include:
 Judge __________________________ County ________________________

Mental health professionals with whom I have had personal experience include:
Name __________________________ City & State _________________________

Please mail this application to:            FACE
                                                         PO Box 2471
                                                         Cinnaminson, New Jersey  08077