A Non-Profit Organization dedicated to serving Independent Shoe Retailers nationwide
Initial Membership Application Form
Your Company Name:
Website:
Mr
Mrs
Ms
First Name:
Last Name:
Address:
City /State /Zip:
Phone:
Fax:
Email:
Your Job Title:
Owner
President
Vice President
Store Manager
General/District Manager
Buyer
Merchandise Manager
Other, please specify:
MEMBERSHIP $95
per Membership Year -- Membership year 10/1-9/30
Total:
Method of Payment:
Check payable to: USRA
Mail check payment to:
USRA Membership Dept
PO Box 4931
West Hills, CA 91308
PayPal
Mastercard
Visa
AMX
Name on Card:
Card Number:
Exp Date:
Security Code:
On Visa, MasterCard and Discover the security code is the three digits to the right of the credit card number in the signature area on back of the card. On American Express, the security is four digits printed (not embossed) on the right front of the card above the credit card number.
Signature:
Credit Card Billing Address:
Same as listed above
See Below
Address:
City/State/Zip:
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