FREE SPEECH COALITION, INC.

APPLICATION FOR MEMBERSHIP

COMPANY NAME:

OWNER/INDIVIDUAL NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP CODE:

TELEPHONE:

FAX:

E-MAIL ADDRESS:

PRINT THIS APPLICATION AND MAIL W/Check or M. O.

MEMBERSHIP TYPE AND ANNUAL DUES

MANUFACTURERS / DISTRIBUTORS / INTERNET SERVICES / MAIL ORDER/ INDUSTRY SUPPORT SERVICES:

(Based on Annual Sales Volume): Annual Sales of $10,000,000 or over

Annual Sales of $5,000,000 thru $9,999,999

Annual Sales of $1,000,000 thru $4,999,999

Annual Sales of $500,000 thru $1,000,000

Annual Sales of less than $500,000

$8,000 per yr.

$4,000 per yr.

$2,000 per yr.

$1,000 per yr.

$500 per yr.

DIRECTORS / PRODUCERS/ LAW FIRMS

$500 per yr.

TALENT AGENTS / DANCE CLUBS (PER CLUB UP TO 10 CLUBS)

  

$300 per yr.

VIDEO RENTAL & RETAIL STORES (PER STORE UP TO 10 STORES)

$300 per yr.

INDIVIDUAL WEB SITES/ WEBMASTER

$300 per yr.

TALENT & OTHER INDIVIDUALS EMPLOYED IN ADULT ENTERTAINMENT INDUSTRY

$50 per yr.

ASSOCIATE MEMBERS (NON-INDUSTRY INDIVIDUALS)

$25 per yr.


Membership Rate __________ X Number of Dance Clubs or Retail Stores ______ = Amount Enclosed $____


PLEASE MAKE CHECKS PAYABLE AND MAIL WITH THIS FORM TO:

FREE SPEECH COALITION

P.O. BOX 10480

CANOGA PARK, CA 91309

(818) 348-9373 • FAX (818) 886-5914

Email – freespeech@freespeechcoalition.com

 PLEASE CHARGE MY CREDIT CARD FOR FULL PAYMENT.

 I WOULD LIKE TO MAKE PAYMENTS. PLEASE CHARGE MY CREDIT CARD AS INDICATED BELOW:

(OPTIONS BELOW ARE ONLY AVAILABLE TO BUSINESS MEMBERS WITH ANNUAL DUES OF $300 OR MORE).

 CHARGE MY CREDIT CARD ON A MONTHLY BASIS (12 PAYMENTS).

 CHARGE MY CREDIT CARD ON A QUARTERLY BASIS (4 PAYMENTS).

 CHARGE MY CREDIT CARD ON A SEMI-ANNUAL BASIS (2 PAYMENTS).

CREDIT CARD INFORMATION

CREDIT CARD NUMBER:

EXPIRATION DATE:

CARD TYPE:    MASTERCARD      VISA    
                          AMERICAN EXPRESS      DISCOVERY    

CARDHOLDER NAME:

CARDHOLDER SIGNATURE:

Contributions or gifts to the Free Speech Coalition are not deductible as charitable contributions,

but may be deductible as ordinary and necessary business expense