_Membership Registration "*" indicates required fields 1Member Info2Contact Info3About You4Interest and Skills5Referral6Member Agreement7Payment8Submit Member Type*Select Former Member if you have been away from PHNC for more than a year. New Member Former Member Last Active Membership Year* Name:* First Name Last Name Nickname:How you would like your first name to appear in the directory. Password* Enter Password Confirm Password Address:* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Primary Phone*Primary Phone* Home Cell Alternate Phone:Alternate Phone Home Cell Email* Email Confirm Email Subdivision: Spouse First Name Spouse Last Name Birthday Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberBirthday Day*01020304050607080910111213141516171819202122232425262728293031State you are originally from:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCanadaUnited KingdomOtherFull time Florida resident?* Yes No Away from Florida address:* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What month do you generally Leave Florida?JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWhat month do you generally return to Florida?JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Interests:Activity InterestsPlease check all PHNC activities of interest to you. Arts & Antiques Book Clubs Bunco Canasta Casual Bridge Couples Dining Out Couples Supper Club Gardening Gals Hand & Foot Holiday Cookie Exchange Intermediate Bridge Ladies Night Out Lunch & a Movie Lunch Bunch Mah Jongg Minglers Singles Pot Luck Two Can Dine for $49 Wine Club for Couples Additional Interests ? I have other Interests not listed. My Additional Interests are:Additional Interest 1Additional Interest 2Additional Interest 3 Add RemoveSkillsWhat are Your Computer Skills?*NoneBasicAverageIntermediateAdvancedPlease select the level that applies.What Programs are you familiar with ?(select all that apply) Word Excel PowerPoint Publisher Photoshop QuickBooks WordPress Web design How did you hear about Palm Harbor Newcomers Club?*FriendFacebookTVNewspaperInternetOtherWho Recommended PHNC to you? Membership AgreementMember Consent* I agree to abide by the Palm Harbor Newcomers Bylaws. PHNC Bylaws PaymentMembership Registration* Price: Form of Payment* Credit Card Check Payment MethodCredit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Billing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment is due within seven days of registration. Make checks payable to: Palm Harbor Newcomers Club (PHNC) Mail to: Palm Harbor Newcomers Club Attn: Membership, 9609 Gretna Green Dr. Tampa, FL 33626 Total Due CommentsThis field is for validation purposes and should be left unchanged.
