Women of the Midwest Membership Form

subject_line

Women of the Midwest Membership Form

Please fill this section out completely with all of your contact information.

Are you a current member? *

Yes

No

First name *

Middle name *

Last name *

Date of birth

Cell Phone *

Home phone

Email address *

Street *

City *

State *

Postal code *

How did you learn about us: *

My friend is a member (please share with us the name of your friend in the additional comments section)

I ran into your website!

I heard about you on radio/TV!

None of the above (please share with us how you found us in the additional comments section)

Additional comments:

Do you have a passport?

Yes

No

Passport number

Passport expiration date

How would you like to pay for the $100.00 membership fee? *

Credit card

Check

Checks can be made out to Executive Travel. Mail your check to:

Executive Travel

Attn: Group Department

1212 O Street

Lincoln, NE 68508

Name on Card *

Credit Card Type *

Credit Card Number *

Security code (CVC code) *

PIN Number (if applicable)

Expiration Date (mm/yy) *

*

clear

Thank you for renewing your membership with Women of the Midwest.

Thank you for becoming a member of Women of the Midwest, we will contact you via email within 2 business days. Please check your inbox and spam-box for emails from info@womenofne.com; add us to your address book.