Member Dues 2017 Step 1 of 4 25% Name* First Last Membership #*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email*This should be the email address of the Knight. Spouses email address can be added in the demographic survey. Home PhoneMobile PhoneNext steps (Dues and Donations) I would like to pay my dues online (now). I would like to purchase a charity brick ($100). I would like to make an additional donation (any amount helps). Please have someone contact me to discuss my dues. Notice about PayPal and Incomplete PaymentsWe are using PayPal to complete the transactions. You do not need to have a PayPal account to pay the dues, you can simply use your credit card on the PayPal screen if you prefer. Please note, once you begin the form to pay your dues, you must complete the payment at PayPal. Otherwise, your form will "time-out" and the website will lock the member number. ****************************************** If you experience technical difficulty, please email John Guerra (email@example.com). ****************************************** Membership InformationOccupation:Marital StatusMarriedSingleWidowedSpouse Contact InformationWe would like to include your wife's contact information in our database. Please provide her name, and any other contact information (such as phone or email).Parish InformationParish*Christ the King Catholic ChurchSt. Bernard of Clairvaux Catholic ChurchSt. Patrick Catholic ChurchSt. Pius X Catholic ChurchSt. Thomas Aquinas Catholic ChurchOther (please specify)Other Parish* I am Safe Environment Certified Safe Environment Certification expiration date (if known) KofC Insurance/Financial ProductsAre you currently purchasing KofC Insurance products?YesNoPlease contact me about purchasing KofC insuranceNext-of-kin Contact InformationYou indicated that you are an Insurance member. We would like to include your next-of-kin information in our membership database. Please provide any next of kin contact information (name, address, phone, email, etc.)Any feedback or suggestions for the Council Annual DuesPlease look at your email or paper statement for the dues amount. Most Members will pay the regular dues amount ($95.00) per year. However, if you qualify for reduced rate (see below), please select the appropriate option.Membership Type*Honorary Member: Member of the Order for more than 25 consecutive years and 65 years of age or older. Honorary Life Members: Members who have attained the actual age of 70 years and who have been members of the Order for 25 consecutive years and those who have been members of the Order for 50 consecutive years, regardless of age.Regular dues (most members will select this option)I am an Honorary Member or Honorary Life Member (see below).I am an Honorary Life Member (see below).I am a Priest.I can claim a disability exemption (form required each year).Expected dues amountIf you used a custom URL to reach this dues payment form, the URL included your dues amount. Please double check the amount above to make sure it matches the calculated dues amount. If it does not match, please email firstname.lastname@example.org before continuing this form.Annual Dues* Price: $0.00 Charity BrickThank you for ordering a charity brick. For each brick that you purchase you need to fill out what you want the brick to say. Inscription is limited to 16 characters per line, 2 line maximum. Please use only one individual or family name per brick. Please allow a few months for the bricks to be placed. We will submit a batch order once enough bricks have been ordered.Inscription*First LineSecond Line Charity Brick* Price: $100.00 Additional Donation*Would you consider paying an extra $3-$5 to offset the cost of dues mailing and online payment processing fees?YesNo, thanksAdditional DonationThank you for offering to make an additional donation. Your donation will go to the charity account and support many of our activities, including the Sisters' Appreciation Dinner, Parish support, seminarian support, women's pregnancy centers, and many more. The Charity account also provides assistance to parishioners in need via the St. Vincent de Paul Society. Members may request assistance in times of need by submitting a written request to the Grand Knight.Additional Donation to Charity AccountPlease enter a whole dollar amount below. Paying using PayPal or Credit CardAlmost done. Just a few questions on the next page and then you will be sent to PayPal to complete your dues payment. No Paypal account required! If you don't have a PayPal account, click the Credit Card option on left side of the PayPal payment screen.Thank you for paying dues online. We will continue to improve this process over time. We ask for your patience and understanding.Total $0.00 Payment via PayPalThank you for paying dues (and/or donation) online. We will continue to improve this process over time. We ask for your patience and understanding. Click Submit to go to PayPalThank youThank you for your time filling out this form.NameThis field is for validation purposes and should be left unchanged.