Kansas City Direct Marketing Membership

* Indicates required field

* First Name:
* Last Name:
Title:
* Company:
Company Type:
* Street Address:
* CIty:
* State:
* ZIP:
Telephone:
Fax:
* Email:

Rates: Check one box only.

* Check One:
Individual - $150
Young Professional - $95
Small Business ( 4 or less in the business) - $275
Corporate (more than 5) - $399
Out-of-Town - $135
Professional in transition - $60
Student - $35
NEW! -- ENHANCED LISTING-$100
Number of additional Corporate member after 9:

List the name, title and email address of each corporate member separately below. 4 person minimum.

Corporate Members:



Payment Information

* Payment Method:
* First Name on Credit Card:
* Last Name on Credit Card:
* Credit Card Number:
(No dashes and spaces please)
* Expiration Date: /
* Credit Card Security Code:
(three or four digit code located on the back of the card)
* Billing Street Address:
* Billing Zip Code: