|
Date:
|
_________________________________ |
| Applying as: | ___ | Active | ___ | Associate | ___ | Affiliate |
|
Name:
|
________________________________________________________ |
|
Pseudonym(s):
|
_________________________________ |
|
Address:
|
_________________________________________________________________________________ _________________________________________________________________________________ |
|
City:
|
___________________________ |
|
State:
|
________________ |
|
Zip:
|
_____________ |
|
Country:
|
______________________ |
|
Home
phone:
|
__________________________ |
|
Work
phone:
|
__________________________ |
|
Fax
phone:
|
__________________________ |
|
Agent name & addr:
|
_________________________________________________________________________________ _________________________________________________________________________________ |
|
Email
address:
|
_____________________________________ (Please list only one.) |
|
Web
page URL:
|
_____________________________________ (Please list only one.) |
If there is any info above that you do not want listed in our Member Directory, or if you would like your directory info to be different from that listed above, please specify here:
How did you find out about HWA?
List qualifying credentials. Attach a separate sheet if necessary. (If applying for Active status, please attach copies of contracts and pay stubs or copyright pages for each qualifying work in order to verify pay rate, word count, and either receipt of payment or publication.)
Dues option:
| ___ |
Standard membership (Includes one Directory entry; one userID for access to HWA's Members Only website) |
| ___ |
Corporate membership (Includes one Directory entry and up to 10 userIDs for access to HWA's Members Only website; all official street mail is sent to a single specified address) |
| ___ |
Family membership (Up to three family members, each with separate Directory listings and separate userIDs for access to the HWA Members Only website; all official street mail is sent to a single specified address) |
| Membership Type | Jan 1 - Mar 31 |
Apr 1 - Jun 30 |
Jul 1 - Sep 30 |
Oct 1 - Nov 30 |
Dec 1 - Dec 31 |
|---|---|---|---|---|---|
| Individual Membership | $65 | $50 | $35 | $20 | Free |
| Corporate Membership | $110 | $95 | $80 | $65 | Free |
| Family Membership | $85 | $70 | $55 | $40 | Free |
|
Credit
card type:
|
___ Visa ___ MC ___ Amex |
|
Card
number:
|
_______________________________ |
|
Expiration
date:
|
_______ / _____________ |
|
CVV2
number*:
|
________________ |
*Your CVV2 number is a 3- or 4-digit number used for additional security in online transactions. On Visa/MasterCard cards, the verification number is a 3-digit number printed on the back of your card. It appears after and to the right of your card number. The American Express verification number is a small 4-digit number printed on the front of your card on the right hand side. If you can't find your CVV2 number, please contact us at treasurer@horror.org.
Fill out your hardcopy of the application form and mail it with your check (drawn in U.S. dollars, please), money order, or credit card instructions and any attached verification papers to:
HWA Membership
244 5th Ave., Suite 2767
New York, NY 10001
U.S.A.