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Membership Form - Individuals
YES, I want to join the PBA! Membership valid for one year to the nearest calendar quarter.
If paying by check, print the completed form and mail to the address below. If
paying by credit card, you may click the submit button below, mail to the address above or fax the complete form to (863)644-3288
Renewal or 3-yr. Extension - Current Members check here
Add your Membership Number (if available)
First Name
Last Name
Company
Address (as it appears on your credit card statement)
City
State
Zip
Phone
Fax
email address (Important)
You will receive full color newsletter via e mail.
I don't have an e mail address. I will pay $39.95 for standard membership to receive the B&W newsletter by U.S. mail
Once my membership is acknowledged, I will call for my free 5-minute consultation with Larry Larsen. If you have selected 1 Year Premium or the 3-Year Standard Membership, please check your choice below:
- DVD
-
OR two of the following
- T Shirt
-
TS1 Explosions!
TS2 Addiction
Size
M
L
XL or
XXL
- Book
PF3
PF4 or
- Peacock Bass Cap
----------------------------------------------------------------------------- Credit Card Billing Information
Visa
MasterCard
American Express
Number
Exp date
Name as it appears on your credit card
Signature_____________________________________________
Submitting this form authorizes PBA to charge my card for my membership fee above. If you prefer, you
may submit this completed form and provide your credit card information by fax or phone.
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