Online Membership Registration

NOTE: While this website has SSL certificate (https:// instead of http://) and is secure, it doesn't hurt to further protect yourself. Ensure that you are using a home or office network instead of a public network. Also, make sure that no one is physically watching you enter your credit card information. If you are concerned about security, you are more than welcome to download the membership registration, fill it in, scan it, and email or postal mail it to us. Thank you.

* indicates required field

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Type of application:*

New Application ($200/year)
Renewal ($175/year)

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Full Name:*

Title:

Company/Organization:

Street Address:*

City / State / Zip:*

Phone #:

Fax #:

Email:*

Re-enter Email:*

Your company/organization's website address:

Cardholder's name as shown on card:*

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Card type (choose one):*

AMEX
Visa
Mastercard
Discovery

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Card number (no spaces or dashes):*

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Card expiration (month):*

01 (January)
02 (February)
03 (March)
04 (April)
05 (May)
06 (June)
07 (July)
08 (August)
09 (September)
10 (October)
11 (November)
12 (December)

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Card expiration (year):*

2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027

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Security Code (on back of card):*

Amount you hereby authorize JFK Rotary to charge to your card (In USD $, no decimals):*

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