Florida Star Fiction Writers Membership Form

Please fill in the form below.

(*) Required Field
Legal Name

FirstLast
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pen Name (if different from Legal Name)

FirstLast
E-mail
example@example.com
PayPal Account E-mail (if different from E-mail)
example@example.com
PayPal ID or Business Name (if different from Legal or Pen name)
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Which of the following applies to you?
Comments/Questions/Anything you'd like us to know about you:
Membership Fees (renewable only in January for $30.00 once the New Member fee is paid at any time during the year:)
prevnext( X )
New Member
January 1st through June 30th

$60.00 Quantity

New Member
July 1st through December 31st

$30.00 Quantity

Total

$0.00
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