WDIFL Membership Mail-In Order
Form
Print Out -
Fill Out - Mail In (US Funds Only)
Please sign me up for WDIFL Membership:
One Year Membership @ $59.95 per year
Total: ________________
Four Month Membership @ $19.95
Total: ________________
Life Time Membership @ $150.00
Total: ________________
______________________________________________
Name: ___________________________________________________________
Address: _________________________________________________________
City: _____________________________________________________________
State: _______________________________________ Zip Code: ____________
Mailing Address (if different): __________________________________________
Phone (Days): ____________________ Phone (Eves): _____________________
e-mail Address: ______________________@_____________________________
Choose your Username and Password must be at least 6 characters long and are case sensitive.
Username: _____________________________
Password: ______________________________
Select Payment Type: (include payment with form)
Check Payment Type: _____Cashiers _____ Money Order _____
Certified Check
_____ Personal Check
Check Number: __________ (personal checks need to clear our bank
before membership is activated)
Make checks payable to: Left
Coast Web Graphics
Mail Order Form To:
Left Coast Web Graphics
WDIFL Membership
210 SW Pine St
Grants Pass, OR 97526
E-mail: Membership Desk