Application for Membership in the
Electronic Parliament USA/Canada

First Name:
Last Name:
Email:
Do you have a home page? URL:
Phone/Fax (Optional):
Mailing Address (Optional):
Street:
City:
State:
Zip/Postal Code:
 
I am a citizen of: USA Canada
Other:
 
 
Do you consider yourself an "undecided voter"? Yes No
 
Are you above or below 18 years of age? Above Below
 
We want you to have the most up-to-date equipment in order to ensure undisturbed communication with us. The latest PCs, monitors and printers will be available to members below wholesale prices with a unique "pay as you can" plan through your EPCARD. Do you want more information about this offer? YesNo
 
 
Are you interested in participating in activities of your local Electronic Parliament chapter? Yes No


 
Membership dues in the U.S. are $3.00 per month, payable with this application and due annually. (U.S. $36.00 - Canadian $45.00)

ATTENTION: Credit card information is not transferred in a secure manner at this time. A secure server is under construction and we will advise you when available. If you feel this is a risk, please pay by check after submitting this form.
Please choose your method of payment: Credit Card
Check (by mail to address below after submitting this form)
Credit Card Number:
Expiration date:
Name on the card:

Please make any check payable to "Electronic Parliamant"and insure that your both NAME and MEMBERSHIP NUMBER are PRINTED on it. You will be issued a membership number immediately after submitting this form. There is no need to include a hard copy of this form with a check.

Mail to one of these addresses:

U.S. Members:
Electronic Parliamant
P.O. Box 221458
Carmel, CA 93922
USA 		Canadian Members:
Electronic Parliamant
P.O. Box 2550
Sidney, B.C. V8L 4B9
Canada