Welcome to ACTRA

Membership Registration Form

Family Membership Application
Family Membership Available by mail only. We must have an application for each family member.


All fields are required
First Name:
Middle Name:
Last Name:
Street:
City:
State:
Zip:	#####
Phone:	(###-###-####)
Email:
Date of Birth:
Social Security Number:
Desired User Name:
Desired Password:
Authorize Payment For:	$65.00 Premier Membership
Home Chapter:
	$30.00 Double Number Request
	$35.00 Dual Chapter Request

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Verification Code:
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