Mr.Mrs.Ms. Please Select One   Name     Street Address where you wish to receive mail            City   State Zip Code Home Phone   Office Phone   Cell Phone E-Mail Address     IF YOU WORK: Name of Employer Job Title   IF YOU ARE A STUDENT: Name of College or University Major/minor You may apply for one of the following classes of annual Membership: PLEASE SELECT ONE   ACTIVEASSOCIATE ACTIVE: You are a Professional engaged in television. ASSOICATE: You are interested in the Advancement of the Arts and Sience of  Television Annual membership rates for ACTIVE and ASSOCIATE members: (rates have been adjusted to reflect market size)  ALABAMA     FLORIDA        Mobile Member $25.00 Naples - Ft, Myers Member $25.00 GEORGIA     Miami - Ft. Lauderdale Member $50.00 Thomasville Member $20.00 Gainesville Member $20.00 LOUISIANA     Jacksonville Member $35.00 Alexandria   Member $20.00 Orlando-Daytona Beach Member $40.00 Baton Rouge Member $25.00 Panama City Member $20.00 Lafayette Member $20.00 Pensacola Member $25.00 Lake Charles Member $20.00 Sarasota Member $40.00 New Orleans Member $35.00 Tallahassee Member $20.00 PUERTO RICO     Tampa-St. Petersburg Member $50.00 All markets New Member Member $40.00 West Palm Beach Member $40.00             Annual membership rates for Students: Click the rate that applies to you.   Member $15.00 Amount paid:   You will receive a free subscription to the Suncoast Chapter's online monthly newsletter TUBE TALK with your membership in the Suncoast Chapter YesNo  METHOD OF PAYMENT VISAMASTERCARDCHECK Address as it appears on billing statement for credit card, if applicable   Name Billing address of this credit card City         State Zip Card Number Expiration Date