Adult New Membership

Use this form only if you are joining as a new Adult Society member.

The Society offers three age groups for adult members. Adult members are classified as Adult (Age 20-59), Senior (Age 60-74) or Senior Elite (75 & up). Age level is based on the age you will turn in the current year, no matter what month. If you qualify for Senior Elite please provide your year of birth below.

There is currently only one level of adult and senior membership:
Classic: Benefit - Porcelain Brooch
Choice or Premier membership is not available at this time.

Membership Level                                                                          

Classic: Adult $38, Senior $33, Senior Elite $25 - Benefit: Porcelain brooch
Credit Card or Check Holder's Information:
Name:
Address:
City:
State:
Zip:
Country:
Phone #:
Email Address:
Enter New Member's Information Here:
(if different than information above)
Name:
Address:
City:
State:
Zip:
Country:
How did you find out about the P. Buckley Moss Society?
Donation to the Moss Foundation
One dollar of your membership dues will be donated to the P. Buckley Moss Foundation for Children's Education. This donation may be tax deductible.
Member Recruitment
If a Society Member has recruited you enter their Membership Number or Name below. Or if you are a member signing up a new member please enter your membership number below. The recruiter will receive a voucher good for $5.00 off their next renewal:
Membership Number or Name to Receive Voucher:

Senior Elite Member's Birth Year:

Choose One:
$38.00 Classic Adult One Year (Benefit: Porcelain Brooch)
$33.00 Classic Senior Rate One Year (60-74)
$25.00 Classic Senior Elite Rate One Year (75 or older)

Notes: