<h4>Individual Membership $60.00</h4>
Please fill out the fields below:
<form action="https://faas.cloud.clickandpledge.com" method="post" name="WAC"><input type="hidden" name="FieldName" value="Salutation" /><select id="FieldValue" name="FieldValue" size="1"><option value="Mr.">Mr.</option><option value="Ms.">Ms.</option><option value="Mrs.">Mrs.</option><option value="Dr.">Dr.</option><option value="Prof.">Prof.</option></select>First Name
<input type="text" maxlength="50" name="BillingFirstName" required="" />
Middle Initial
<input type="text" maxlength="1" name="BillingMI" required="" />
Last Name
<input type="text" maxlength="50" name="BillingLastName" required="" />
<input type="email" maxlength="50" name="BillingEmail" required="" />
Phone
<input type="tel" maxlength="50" name="BillingPhone" />
Street Address
<input type="text" maxlength="50" name="BillingAddress1" />
City
<input type="text" maxlength="50" name="BillingCity" />
State
<select id="BillingStateProvince" name="BillingStateProvince" size="1"><option value="Alabama">Alabama</option><option value="Alaska">Alaska</option><option value="Arizona">Arizona</option><option value="Arkansas">Arkansas</option><option value="Armed Forces- Africa">Armed Forces- Africa</option><option value="Armed Forces- Americas">Armed Forces- Americas</option><option value="Armed Forces- Canada">Armed Forces- Canada</option><option value="Armed Forces- Europe">Armed Forces- Europe</option><option value="Armed Forces- Middle East">Armed Forces- Middle East</option><option value="Armed Forces- Pacific">Armed Forces- Pacific</option><option value="California">California</option><option value="Colorado">Colorado</option><option value="Connecticut">Connecticut</option><option value="Delaware">Delaware</option><option value="District of Columbia">District of Columbia</option><option value="Federated States of Micronesia">Federated States of Micronesia</option><option value="Florida">Florida</option><option value="Georgia">Georgia</option><option value="Guam">Guam</option><option value="Hawaii">Hawaii</option><option value="Idaho">Idaho</option><option value="Illinois">Illinois</option><option value="Indiana">Indiana</option><option value="Iowa">Iowa</option><option value="Kansas">Kansas</option><option value="Kentucky">Kentucky</option><option value="Louisiana">Louisiana</option><option value="Maine">Maine</option><option value="Maryland">Maryland</option><option value="Massachusetts">Massachusetts</option><option value="Michigan">Michigan</option><option value="Minnesota">Minnesota</option><option value="Mississippi">Mississippi</option><option value="Missouri">Missouri</option><option value="Montana">Montana</option><option value="Nebraska">Nebraska</option><option value="Nevada">Nevada</option><option value="New Hampshire">New Hampshire</option><option value="New Jersey">New Jersey</option><option value="New Mexico">New Mexico</option><option value="New York">New York</option><option value="North Carolina">North Carolina</option><option value="North Dakota">North Dakota</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Ohio">Ohio</option><option value="Oklahoma">Oklahoma</option><option value="Oregon">Oregon</option><option value="Palau">Palau</option><option value="Pennsylvania">Pennsylvania</option><option value="Puerto Rico">Puerto Rico</option><option value="Rhode Island">Rhode Island</option><option value="South Carolina">South Carolina</option><option value="South Dakota">South Dakota</option><option value="Tennessee">Tennessee</option><option value="Texas">Texas</option><option value="Utah">Utah</option><option value="Vermont">Vermont</option><option value="Virgin Islands- US">Virgin Islands- US</option><option value="Virginia">Virginia</option><option value="Washington">Washington</option><option value="West Virginia">West Virginia</option><option value="Wisconsin">Wisconsin</option><option value="Wyoming">Wyoming</option></select>Zip
<input type="text" maxlength="20" name="BillingPostalCode" />
<h3>Payment Information</h3>
<input type="hidden" name="PaymentType" value="CreditCard" />
Name On Card
<input type="text" maxlength="50" name="NameOnCard" required="" />
Card Number
<input type="text" maxlength="17" name="CardNumber" required="" />
Cvv2
<input type="text" maxlength="4" name="Cvv2" required="" />
Expiration Date
<select id="ExpirationMonth" name="ExpirationMonth"><option value="01">January</option><option value="02">February</option><option value="03">March</option><option value="04">April</option><option value="05">May</option><option value="06">June</option><option value="07">July</option><option value="08">August</option><option value="09">September</option><option value="10">October</option><option value="11">November</option><option value="12">December</option></select><select id="ExpirationYear" name="ExpirationYear"><option value="09">2009</option><option value="10">2010</option><option selected="selected" value="11">2011</option><option value="12">2012</option><option value="13">2013</option><option value="14">2014</option><option value="15">2015</option><option value="16">2016</option><option value="17">2017</option><option value="18">2018</option><option value="19">2019</option><option value="20">2020</option></select>
<h3>Newsletters</h3>
<input type="hidden" name="eNewsletterName1" value="ConstantContact" />
World Affairs Council Newsletter: <input id="SubscribeList1" type="checkbox" name="SubscribeList1" value="World Affairs Council General List" />
Community Programs Weekly Newsletter: <input id="SubscribeList1" type="checkbox" name="SubscribeList1" value="Community Programs Weekly Newsletter" />
Global Classroom Weekly Newsletter: <input id="SubscribeList1" type="checkbox" name="SubscribeList1" value="Global Classroom Weekly Newsletter" />
YPIN Weekly Newsletter: <input id="SubscribeList1" type="checkbox" name="SubscribeList1" value="YPIN Weekly Newsletter" />
<input type="submit" name="Submit" />
<input type="hidden" name="ItemID1" value="1" />
<input type="hidden" name="ItemName1" value="Individual" />
<input type="hidden" name="Quantity1" value="1" />
<input type="hidden" name="UnitDiscount1" value="6" />
<input type="hidden" name="UnitPrice1" value="60" />
<input type="hidden" name="SKU1" value="60200-INDIVIDUAL" />
<input type="hidden" name="WID" value="68379" />
<input id="SendReceipt" type="hidden" name="SendReceipt" value="true" />
<input id="OrderMode" type="hidden" name="OrderMode" value="Production" />
<input id="TransactionType" type="hidden" name="TransactionType" value="Payment" />
<input type="hidden" name="OnSuccessUrl" value="https://www.world-affairs.org/get-involved/become-a-member/membership-2/successful-transaction/" />
<input type="hidden" name="OnDeclineUrl" value="https://www.world-affairs.org/get-involved/become-a-member/membership-2/declined-transaction/" />
<input type="hidden" name="OnErrorUrl" value="https://www.world-affairs.org/get-involved/become-a-member/membership-2/transaction-error/" />
<input type="hidden" name="AccountGuid" value="161c6015-7f70-4f3f-9c1f-028d4f79de62" />
<input type="hidden" name="AccountID" value="18544" />
</form>
Originally posted by Support.Department
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