Please print this page, complete it, and mail with your donation.
 
 
Fathers' and Children's Equality, Inc.

MEMBERSHIP APPLICATION

Date _______________    [_] New Membership     [_] Renewal      [_] Contribution

[_] Regular membership $75.00 per year

[_] Patron membership $150.00 or more per year

[_] Life Membership $750.00 in one year      Amount Enclosed $______________

Please make check or money order payable to "FACE" or use your credit card

Credit card payments can only be accepted at FACE meetings with the card present.

[_] Visa       [_] MC      [_] AMEX

Credit Card Number: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Expiration date (Month/Year): |__|__|/|__|__|__|__|

Signature (for credit card): __________________________________________

Name: _________________________________________________________

Address: ________________________________________________________

_______________________________________________________________

City: __________________________ State: ________  Zip: ________________

Residence County: ________________________________________________

Your Date of Birth: ____________________________

Phones:

[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________

[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________

[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________

[_] Home, [_] Work, [_] Cell, [_] Other ___________________________________

Email address: ___________________________________________________

Social networking sites (MySpace, FaceBook, Twitter, LinkedIn, etc.):

________________________________________________________________

Are you registered to vote?  [_] Yes    [_] No

If not registered, are you eligible to vote?   [_] Yes    [_] No   [_] I don't know.

[_] FACE may use my name as a supporter for legislative purposes. (PLEASE CHECK)

How did you learn of FACE? __________________________________________

________________________________________________________________

I have _____ child(ren).  My youngest child's date of birth is: _____/_____/_______

How many overnights per month do your children spend with you? _____________

Jurisdiction of my case is: County: _____________________  State: ___________

Judge(s) with whom I have had personal experience include:

Judge: ____________________________ County: ________________________

Judge: ____________________________ County: ________________________

Judge: ____________________________ County: ________________________

Lawyers with whom I have had personal experience include:

Name: ____________________________ City & State: _____________________

Name: ____________________________ City & State: _____________________

Name: ____________________________ City & State: _____________________

Mental health professionals with whom I have had personal experience include:

Name: ____________________________ City & State: _____________________

Name: ____________________________ City & State: _____________________

Name: ____________________________ City & State: _____________________

Please print, fill out and mail this application with your check or money order to: 

                                                            FACE 
                                                            P.O. Box 3302 
                                                            Cherry Hill, NJ 08034 
 

Credit card payments can only be accepted at FACE meetings with the card present.