New Membership Form

    Date (required)

    Name (First, MI, Last) (required)

    Employment Agency (required)

    Position (required)

    Home Address (required)

    City (required)

    State (required)

    Zip Code (required)

    Home Phone Number (required)

    Mobile Phone Number (required)

    Personal Email Address (required)

    Dues can be automatically debited from your checking or savings account or billed to your credit card. Please indicate your preferred method of payment.

    Payment Choice

    For credit card payment please complete the following:

    Select Credit Card Type

    Credit Card Number

    Billing Address (if different than above)

    Expiration Date (required) month and year 00/00 - for example the first two digits for the month, and last two digits for the year

    For payment from your bank account please upload a photo or a scanned copy of your voided check.

    Upload image of voided check (may be a .pdf, .jpeg, .png, or .gif file)

    By clicking the "submit" button, I authorize POSA/AZCOPS to deduct $25.00 a month using the method indicated above.