Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
This form enables members of Council 11879 to submit credit card payment of dues on-line. Payments are processed via the council's Square account and subject to Square processing fees.
My Products
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( X )
Current Year Annual Membership Dues
$
29.00
Quantity
1
Item subtotal:
$
0.00
Optional Buck-a-Month donation
Supports pro-life programs and activities
$
12.00
Quantity
1
2
Item subtotal:
$
0.00
Optional Penny-a-Day donation
Supports pro-life programs and activities
$
3.65
Quantity
1
2
Item subtotal:
$
0.00
Past due annual dues (previous year)
If you are submitting past dues, please enter them here. Buck-a-month and Penny-a-Day amounts remain the same and can be added via the number counter on those line items
$
29.00
Quantity
1
2
Item subtotal:
$
0.00
Credit Card
Total Purchase Price
Net bank Deposit after fees
Submit
Should be Empty: