Non-profit Organization

Organization Main Contact Title

Organization Name

Focus Area

Organization Street

Organization City

State

State - Non US

Zip Code

Registrant State

Membership Fees

Total Amount Due ($)

Discount

I received a discount code

Yes

Discount Code

Payment Method

Credit CardCheck by mail

First Name on Card

Last Name on Card

Billing Full Name

Cardholder's Email

Used for receipt

Cardholder address same as attendee?

YesNo

Edit section title

Cardholder Country

Cardholder Address

Cardholder City

Cardholder State

Cardholder Non US State

Cardholder Zip/Postal Code

Cardholder State

Credit Card Number

Expiration Month (##)

Expiration Year (##)

CVC (##)

Please make all checks payable to "Commonweal / Somos El Poder", and write in the memo "SEP membership"

Mail checks to:
Commonweal / Somos El Poder

P.O. Box 316

Bolinas, CA 94924