Annual Membership Application

Member Information

First Name *

Middle Name

Last Name *

Title

Title 2 (if applicable)

Professional Designation (Dr., EFO, CFO, etc.)

Organization name (if applicable)

Email Address *

Street Address

City

State/Province/Region

Zip/Postal Code

Country

Phone Number

Annual Donation Level

Advocates - This level of membership support intended for those affected by fire. (Burn survivor or family member of someone lost to fire)

Platinum ($1,000 and up)

Diamond ($500 and up)

Gold ($250 and up)

Silver ($100 and up)

Total amount of Donation: (please enter exact amount as levels above provide ranges i.e., $125.00) *

Supporter - This level of membership support intended for individuals who wish to support advocates and their mission.

Platinum ($1,000 and up)

Diamond ($500 and up)

Gold ($250 and up)

Silver ($100 and up)

Method of Payment: *

Check (please mail to address below)

Credit Card

Corporate - This level of membership support intended for companies and organizations who wish to support the advocates and their mission.

Please mail checks, along with a completed form to:

Common Voices
P.O. Box 162
Pleasant View, TN 37146

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

CVV Code (3 digit code on back)

Additional Comments/Information:

Thank you for your support! Your continued support will help us expand our efforts to create a Fire Safe America, turning tragedy into advocacy. You are appreciated, we are glad to have you on our team! LOOK UP for safety....your life and the lives of your family could depend on it.