Western Province Life Membership Program Registration

Western Province Life Membership Program Registration

Please fill out the form below to join the Western Province Life Membership Program.
Name: Title, First Name, Middle Initial, Last Name

First NameMiddle NameLast Name
Email*
example@example.com
Membership number*
Phone Number*
Please enter a valid phone number.
Current Chapter*
Chapter of Initiation/Year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select One Province Lifetime Payment Option below:
prevnext( X )
One-Time Membership FeeOne-time payment for Life Membership, Office of KOE will send an invoice
$2,000.00 Quantity



Subscribing Membership Deposit (Option A)An initial deposit is required to establish a subscribing membership. The Office of the Keeper of Exchequer (KOE) will issue an invoice reflecting a $1,000.00 deposit, along with two (2) additional line items of $500.00 each. Reminder notices for the outstanding balances will be distributed on a biweekly basis, beginning within two weeks of the initial deposit. Payment is due immediately upon receipt of each notice.
$1,000.00 Quantity



Subscribing Membership Deposit (Option B)An invoice will be issued by the Office of the Keeper of Exchequer for an initial membership deposit of $1,000.00, which will include one (1) additional line item of $1,000.00. A reminder notice for the remaining balance will be sent within two weeks of the initial deposit, with payment due immediately upon receipt of notice.
$1,000.00 Quantity



Total

$0.00
Approver Comments (For Internal Use:
Should be Empty: