WDIFL Membership Mail-In Order Form
Print - Fill Out - Mail In (US Funds Only)

Please sign me up for WDIFL Membership:

One Year Membership @ $69.95 per year

Total: ________________

Four Month Membership @ $23.95

Total: ________________

Life Time Membership @ $175.00

Total: ________________

______________________________________________

Name: ___________________________________________________________

Address: _________________________________________________________

City: _____________________________________________________________

State: _______________________________________ Zip Code: ____________

Mailing Address (if different): __________________________________________

Phone (Days): ____________________ Phone (Eves): _____________________

e-mail Address: ______________________@_____________________________

Choose your Username and Password must be at least 6 characters long and are case sensitive.

Username: _____________________________

Password: ______________________________

Select Payment Type: (include payment with form)

Check Payment Type: _____Cashiers _____ Money Order _____ Certified Check
_____ Personal Check
Check Number: __________ (personal checks need to clear our bank before membership is activated)

Make checks payable to: Left Coast Web Graphics

Mail Order Form To:
Left Coast Web Graphics
WDIFL Membership
210 SW Pine St
Grants Pass, OR 97526

E-mail: Membership Desk

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