Hudson Pride Connections Center Membership
First Name *
Last Name *
Business *
Email *
Address *
City State Zip *
Type of Meembership *
(select one from list)
(select one)
Community Member ($50)
Community Member Family ($80)
Non Profit Member ($100)
Vendor Member ($1,000)
Sponsor: Silver ($2,500)
Sponsor: Gold ($5,000)
Sponsor: Platinum ($10,00)
Pay By (select one) *
(select one from list)
(select one)
Check
Credit Card via this form
Pay Pal via Membership Web Page
If you are paying through the PayPal link on the
Become a Member web page
, there is no need to enter
credit card Number
,
V-Code
, or
Expiration Date
on this form.
Credit Card Type *
(select one from list)
(select one)
VISA
Master Card
American Express
Discover
Billing name if different from above
Billing Address
City State {billtxt_zip}
Credit Card Number
(if not paying by PayPal)
V-Code
(if not paying by PayPal)
Expiration Date
(if not paying by PayPal)
Name as it appears on card
Mail to Hudson Pride Connections Center
32 Jones Street
Jersey City, NJ 07306
* = Required fields
