Kansas Explorers Club

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Your Name: *

E-mail: *

Address: *

City: *

State: *

Zip code: *

Phone:

Cell:

Family Names:
Please list all family names

Nicknames:
Please list what name you would rather be called.

Membership Information

I want to help out with the postage stamp increase!

*just enter a dollar figure that you would like to cover

The total amount charged to your credit card will be
$

1 Year

3 Years

5 Years

10 Years

The billing address must match billing address on the credit card to have your transaction approved.

Credit Card Information
Card Number	Visa, MasterCard, American Express, Discover
Expiration Date
Security Code