Organization Membership Application

"*" indicates required fields

Name of Organization/Business*

Organizational Membership Fee of $30 includes 1 primary member. Additional people from the organization may be added at $10 per person.

Email*

Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Primary "Representative" Information Included in Organizational Fee

* Note that only the Primary Representative Member may vote in the DATV Annual Election. *

First Name

Last Name

Date of Birth

Phone

Address

Street Address City State ZIP Code

Number of Members*

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Additional Member(s): $10.00 Fee per each additional member

First Name

Last Name

Date of Birth

Phone

Address

Street Address Address Line 2 City State ZIP Code

Payment Information

Annual Fee

Price:

Annual Fee

Price:

Annual Fee

Price:

Annual Fee

Price:

Annual Fee

Price:

Annual Fee

Price:

Annual Fee

Price:

Make your online payment

Online

Note: If you wish to pay by cash or check please e-mail: [email protected]

Please mail your check to our office
Dracut Access Television, Inc.
91 Mill St. Suite 8
Dracut, Ma 01826

Pay with Credit Card

American Express

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MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Phone

This field is for validation purposes and should be left unchanged.

Organization Membership Application

Primary "Representative" Information Included in Organizational Fee

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Payment Information

Contact Us

Schedules

Livestream

Get Involved

About

Links

Hours of Operation

Organization Membership Application

Primary "Representative" Information *Included in Organizational Fee*

Additional Member(s): *$10.00 Fee per each additional member*

Additional Member(s): *$10.00 Fee per each additional member*

Additional Member(s): *$10.00 Fee per each additional member*

Additional Member(s): *$10.00 Fee per each additional member*

Additional Member(s): *$10.00 Fee per each additional member*

Additional Member(s): *$10.00 Fee per each additional member*

Payment Information

Contact Us

Schedules

Livestream

Get Involved

About

Links

Hours of Operation

Primary "Representative" Information Included in Organizational Fee

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member

Additional Member(s): $10.00 Fee per each additional member