VIPCA Personal/Affiliate Membership Form

VIPCA Personal/Affiliate Membership Form
Membership Type
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Phone Number/WhatsApp*

Country CodeArea CodePhone Number
Business/Yacht Club/Affiliate Entity Name
Relation to VIPCA*

I’m a VIPCA SupplierI'm a VIPCA vessel owner or VIPCA managerI'm work in a business that serves or services VIPCA clients / membersOther
Website
Date of Birth*

DayMonthYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Subscription Date

MonthDayYear
Date
My Products
prevnext( X )
Personal Membership
$150.00

Total

$0.00
Auto Renew?*

YesNo

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.