Please TYPE IN your information, print out this page, and mail it with your payment to:

The Cinema Club
P.O. Box 42126
Washington D.C. 20015

If you wish for membership passes to be mailed to separate addresses, please fill out a separate form per address.

THE SOUTH FLORIDA CINEMA CLUB - 2011-2012 Series
Full Name:
Returning Member? How many people are joining?
Additional Names:
Address Line 1:
Address Line 2:
City: State: Zip Code:
Phone: Email:
Additional Notes:
IF PAYING BY CHECK: Total Enclosed: Check #
Membership:
IF PAYING BY CREDIT CARD: Total to be charged:
Membership:
Billing Zip Code (if different): Card type: VISA MASTERCARD
Card # Expiration Date (MM/YY):


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