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Membership Renewal Application

If you would like to apply and pay online, please complete this form.
Ask a

1st Member's Name:  

2nd Member's Name:

Additional Family Members (Parakeets under 18):

Street Address:   City:   State:   ZIP:


Member 1 Island Name (if any):      E-Mail: 
Best # to Reach You:                   Birthday: 


Member 2 Island Name (if any):      E-Mail: 
Best # to Reach You:                   Birthday: 


I am interested in assisting in the following (check all that apply):
Charities
Activities & Events
Host an Event
Organize an Event or Trip
Website Design

Do you have any other skills or resources that you would consider accessing to help the 5 O'Clock Phlock?


After clicking on the "Submit Form and Pay" button you will be taken to the payment screen.  We are accepting payments using the PayPal service. You do not have to have a PayPal account to continue.  Credit and Debit Cards are accepted.  A $2 convenience fee will be added to your total.  Dues are not tax deductible as a charitable donations.

If you can read this, don't touch the following text fields.