Name:______________________
Address:_______________________
Address:_______________________
City:__________________________
State:__________Zip:____________
Phone: ________________________
Country: _______________________

Please sign me up for the following:

_____ New Membership
_____ Renewal, ID# - ____________________

If you are renewing your MechForce
membership and you are currently a
Chapter member; please provide us
with your Chapter name:

LONE WOLVES

I have enclosed my membership fee of:

_____ $20.00 - FULL Membership
_____ $5.00 - ASSOCIATE Membership
_____ CASH _____ CHECK

CREDIT CARD: _____ Visa _____ MC _____ Discover
CARD NUMBER:______________________________
CARD EXP. DATE: month ________ year __________

____________________________________________
Name of Cardholder ( please print )

______________________________________
Cardholder Signature

For Full membership applications, please
include additional postage if outside
the USA.
_____ $5.00 USD- Canada and Mexico
______ $10.00 USD- Other International

Total Amount Enclosed: __________________

Please choose one Unit Affiliation:

_____ Bandit Dingdoms
_____ Capellan Confederation
_____ Draconis Combine
_____ Federated Commonwealth
_____ Free Rasalhague Republic
_____ Free Worlds League
_____ Lyran Alliance
_____ Magistracy of Canopus
_____ Mercenary
_____ Periphery Independant
_____ Outworlds Alliance
_____ Clan Smoke Jaguar
_____ Clan Ghost Bear
_____ Clan Diamond Shark
_____ Clan Jade Falcon
_____ Clan Steel Viper
_____ Clan Wolf
_____ Clan Nova Cat
_____ ComStar
_____ St. Ives Compact
_____ Taurian Concordat
_____ World of Blake

Send to:
FASA Corporation
Attention: MechForce
1100 W. Cermak - Suite B305
Chicago, IL 60608

Payment in US Dollars only.
Make ALL checks and money orders
payable to:
FASA Corporation

DO NOT SEND CASH

Please allow 4-6 weeks for delivery.