Direct Membership Application Only

To be used if you have already submitted payment for your direct membership.

Membership Option *

• New Direct Member
• Renewing Direct Member

This membership is for: *

• Myself
• A Gift for Family or Friend (Complete Info at the Bottom)

Direct Member Name *

First

Last

Address *

Address Line 1

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email *

Phone *

Primary Interest in Joining Multiples of America *

• I have multiples, but there is no club in my area.
• I have multiples, but am no longer affiliated with a club.
• I have multiples, but the club nearest me doesn’t have programming to meet my needs. (Please explain below.)

and they Person

If the local club near you doesn't have support to meet your needs, please let us know what you are needing and how they are unable to meet those needs.

Is there anything else you would like us to know about your family, your support interests, or how we can best serve you?

Name of Person Giving the Gift Membership

First

Last

Email of the Person Giving the Gift Membership

I Wish for My Gift to Remain Anonymous

• Yes
• No

SUBMIT