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Name
*
First
Middle
Last,Suffix
Email
*
Phone
*
1. Pay Event Registration
2. Pay For Merchandise (call office for details and pricing)
3. Donate to PSSR Annual Appeal
4. Purchase a Life Membership (call office for details and pricing)
5. Pay for Admissions Fees & Dues (Amount from your New Member Statement)
Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card
*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
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2030
2031
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2035
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2038
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2040
2041
2042
2043
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Security Code
Cardholder Name
Total
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