Friends Family Civitan Club Dues Payment Form

Thank you for choosing to be a Civitan!

Family dues may be paid annually, quarterly or monthly. One dues payment covers a family membership for all members of a household.

Monthly Family Dues: $15.00
Quarterly Family Dues: $45.00
Annual Family Dues: $180.00

Friends Family Club Join Form

Primary Member Name(Required)

First Last

Primary Member Email(Required)

Primary Member Birthday(Required)

Primary Member Phone

Phone Type

Primary Member Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Who invited you to join?

(Sponsor)

Primary Member Spouse/Partner Name

Primary Member Employer

Additional Family Member #1

Full Name & Birthday

Additional Family Member #2

Full Name & Birthday

Additional Family Member #3

Full Name & Birthday

Additional Family Member #4

Full Name & Birthday

Additional Family Member #5

Full Name & Birthday

Family Dues Payment Type(Required)

By choosing a dues type below, you are agreeing to family club recurring dues payments to automatically process at the interval of your choice. Payments are processed on the 15th of each month.

Credit/Debit Card Number(Required)

Security Code(Required)

Expiration Date(Required)

Billing Address

(If different than address of Primary Member entered above)

Street Address City State / Province / Region ZIP / Postal Code

Recurring Payment Agreement

By checking the box below, you agree that a recurring payment to Civitan International will be automatically processed at the amount and frequency selected above until such time as you choose to end this membership.

Yes

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