Application for MembershipIf you’d prefer to download the application, click the button below.Download ApplicationApplication for 100 Club Membership The 100 Club of Southeast Texas needs your help! Show our peace officers and firefighters that you are behind them by joining the 100 Club of Southeast Texas. All memberships are Tax Deductible. (IRS tax exempt NO. 76-02-61811)Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business NameEmail* Business PhoneHome Phone*Mobile PhoneMembership Options*Mail-In Membership Dues and Corporate MembershipsPay Membership Dues OnlinePlease SelectChoose Your Membership Level (Mail-in Only)Please selectPrivate Individual Annual Membership $100Private Individual Lifetime Membership $1000Private Individual Lifetime Membership (4 payments of $250)Annual Law Enforcement/Firefighter $25Lifetime Law Enforcement/Firefighter $250Corporate Bronze Membership $5,000Corporate Silver Membership - $10,000Corporate Gold Membershp $15,000Corporate Platinum Membership $25,000Includes convenience fee.Choose Your Membership Level (Includes Convenience Fee)*Please selectPrivate Individual Annual Membership $103.20Private Individual Lifetime Membership $1,032.00Private Individual Lifetime Membership (4 payments of $258)Lifetime Law Enforcement/Firefighter $258.00Annual Law Enforcement/Firefighter $25.80 I would like four decals instead of usual twoTotal $0.00 Consent I agree my credit card will automatically be charged annually the cost of my membershipCredit CardAmerican ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.