Adult New Membership

Use this form only if you are joining as a new Adult Society member.

The Society offers three age groups for adult members. Adult members are classified as Adult (Age 20-59), Senior (Age 60-74) or Senior Elite (75 & up). Age level is based on the age you will turn in the current year, no matter what month. If you qualify for Senior Elite please provide your year of birth below.

Membership Level                                                                          

Classic: Adult $38, Senior $33, Senior Elite $25 - Benefit: Porcelain brooch

Choice: Adult $85, Senior $80, Senior Elite $70- Benefit: Sterling silver bead

Premier: Adult $100, Senior $95, Senior Elite $85 - Benefit: Sterling silver bead and porcelain brooch

Premier Gold Upgrade: $500, 14k gold bead and porcelain brooch

Credit Card or Check Holder's Information:
Name:
Address:
City:
State:
Zip:
Country:
Phone #:
Email Address:

Enter New Member's Information Here:
(if different than information above)
Name:
Address:
City:
State:
Zip:
Country:

How did you find out about the P. Buckley Moss Society?

Donation to the Moss Foundation
One dollar of your membership dues will be donated to the P. Buckley Moss Foundation for Children's Education. This donation may be tax deductible.

Member Recruitment
If a Society Member has recruited you enter their Membership Number or Name below. Or if you are a member signing up a new member please enter your membership number below. The recruiter will receive a voucher good for $5.00 off their next renewal:
Membership Number or Name to Receive Voucher:

Senior Elite Member's Birth Year:


Choose One:
$38.00 Classic One Year (Benefit: Porcelain Brooch)
$33.00 Classic Senior Rate One Year (60-74)
$25.00 Classic Senior Elite Rate One Year (75 or older)
$85.00 Choice One Year (Benefit: Sterling Silver Bead)
$80.00 Choice Senior Rate One Year (60-74)
$70.00 Choice Senior Elite Rate One Year (75 or older)
$100.00 Premier One Year (Benefit: Porcelain Brooch and SS Bead)
$95.00 Premier Senior Rate One Year (60-74)
$85.00 Premier Senior Elite Rate One Year (75 or older)
$500.00 Premier Gold Upgrade One Year (14k Gold Bead)


Notes: