Associate Member Application

"*" indicates required fields

Date of Application:*

Membership #

Billing Contact Name*

Enter the name of the person who should be contacted regarding any questions about the account.

First Last

Name of Associate Member Applicant:*

First Last

Name of Associate Member Applicant:

First Last

Address*

Street Address City State ZIP Code

Associate Applicant Phone:

Relationship to regular member*

Associate memberships are only available to children of the regular member household that are over the age of 21, or a mother, father or mother-in-law or father-in-law not gainfully employed and living permanently with the regular member.

Phone*

Email*

1. Identification:*

Accepted file types: jpg, jpeg, png, gif.

Please upload a photocopy of a picture identification for example a driver's license.

2. Proof of Residency:*

Max. file size: 10 MB.

Please provide two forms of proof of residency in the form of bills that include your address within the Pearl River Fire District or Pearl River School District. Examples include: tax bill, utility bill, water bill or phone bill.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

3. Fee*

Price:

Associate Member Application fee: $100.00+ tax (8.375%)

Convenience Fee*

Price:

Total

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Name

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Associate Member Application

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