Self Reliance Membership Rapid Enrollment Form

Front Sight 912 Lifetime Membership

Yes Dr Piazza, I participated in the 9/12/2009 tea party rallys accross the United States, and I'd like to take advantage of your 912 Lifetime Membership. I understand this is an individual membership that I'm being allowed to purchase at a significantly reduced cost.

The 912 Membership Includes the following benefits:

912 Membership Payment

____ I am making a single payment of $912.

Your Name:________________________________________________________________

Address:
__________________________________________________________________

City: ______________________________________ State: _______ Zip Code: ___________

Home Phone: __________________________ Work: _______________________________

Credit Card Number: _____________________________________ Expires: _____________
(VISA, MasterCard, Discover, American Express or a combination of cards for the single payment)

Signature: ______________________________________________ Date: _____________

Fax Your Rapid Enrollment Form Immediately to 707.837.0694
If Paying By Check, Mail this Form to 7975 Cameron Drive, #900, Windsor, CA 95492
If You Would Like to Enroll and Have Questions, Feel Free to Call Us at 1.800.987.7719

Deadline to enroll is midnight, Friday, October 16, 2009