Membership Registration

Name

This field is for validation purposes and should be left unchanged.

Member Type*

New Member

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 Zip Code

Primary Phone*

Home

Cell

Alternate Phone:

Alternate Phone

Home

Cell

Email*

Email Confirm Email

Subdivision:

Spouse First Name

Spouse Last Name

Birthday Month*

Birthday Day*

State you are originally from:*

Full time Florida resident?*

Yes

No

Away from Florida address:*

Street Address City State ZIP Code

What month do you generally Leave Florida?

What month do you generally return to Florida?

How did you hear about Palm Harbor Newcomers Club?*

Who Recommended PHNC to you?

Membership Agreement

Payment

Membership Registration*

Price:

Form of Payment*

Credit Card

Check

Payment Method

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address*

Street Address City 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, 3446 Killdeer Place, Palm Harbor, FL 34685

Total Due

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Year of Previous Membership

Membership Registration