Mr.Mrs.Ms. Please Select One   Name     Street Address where you wish to receive mail            City   State Zip Code Home Phone   Office Phone   Cell Phone E-Mail Address     IF YOU WORK: Name of Employer Job Title   IF YOU ARE A STUDENT: Name of College or University Major/minor You may apply for one of the following classes of annual Membership: PLEASE SELECT ONE   ACTIVEASSOCIATE ACTIVE: You are a Professional engaged in television. ASSOICATE: You are interested in the Advancement of the Arts and Sience of  Television Annual membership rates for ACTIVE and ASSOCIATE members: (rates have been adjusted to reflect market size)  ALABAMA     FLORIDA        Mobile Member $25.00 Naples - Ft, Myers Member $25.00 GEORGIA     Miami - Ft. Lauderdale Member $50.00 Thomasville Member $20.00 Gainesville Member $20.00 LOUISIANA     Jacksonville Member $35.00 Alexandria   Member $20.00 Orlando-Daytona Beach Member $40.00 Baton Rouge Member $25.00 Panama City Member $20.00 Lafayette Member $20.00 Pensacola Member $25.00 Lake Charles Member $20.00 Sarasota Member $40.00 New Orleans Member $35.00 Tallahassee Member $20.00 PUERTO RICO     Tampa-St. Petersburg Member $50.00 All markets Member $40.00 West Palm Beach Member $40.00             Annual membership rates for Students: Click the rate that applies to you.   Member $15.00 Amount paid:   You will receive a free subscription to the Suncoast Chapter's online monthly newsletter TUBE TALK with your membership in the Suncoast Chapter YesNo  METHOD OF PAYMENT (Credit Card required when E-Mailing Membership Application VISAMASTERCARD  Address as it appears on billing statement for credit card, if applicable   Name Billing address of this credit card City         State Zip Card Number Expiration Date