Application Type	New Member   Renewing Member
First Name
Last Name
Alias
Birthday	mm/dd/yyyy
Street Address	1234 Some St., Apt 34
City, State Zip Code	,
Primary Phone	- - 123-456-7890
Secondary Phone	- - 123-456-7890
Email Address	user@somedomain.com
Don't send me email	Checking this button will limit your receipt of most Krewe of Chaos group communications including the newsletter.
Mailing Address, if different from above	Street or PO Box City, State Zip  ,
Other Krewe members at this address
Areas of Interest
Occupation
Membership Type	General (Individual) - $25.00 Complete application and pay $25.00 membership fee. Renewable annually on September 1st. Shall have one(1) vote. Fleur-di-Lis (Business / Individual) $250.00 Complete application and pay $250.00 membership fee. Renewable annually on September 1st. Shall have one(1) vote. May, by choice, have one ½-page advertisment in the Krewe of Chaos newsletter.
Order Name Tag	If you want to order a name tag now, please click on the button. The cost is $10. Please make sure that your name is spelled correctly above. I will order my name tag later.
Conduct and Waiver	By signing this Membership Application, the undersigned applicant agrees to, as to his or her duties as a member, conduct themselves so as to conform to the By-Laws of the Krewe of Chaos Inc. and any rules and regulations duly and validly adopted by the Directors, Officers, Committees, or Membership of the Krewe of Chaos Inc. The undersigned further agrees, in connection with their participation or attendance in or at any event held by or for the benefit of the Krewe of Chaos Inc to always comply with all applicable laws. Failure to honor these commitments set out above may cause termination of membership. For, and in consideration of, the acceptance of this Membership Application and of my being a member of the Krewe of Chaos Inc with all its benefits and privileges, the undersigned does hereby agree to protect and indemnify and hold harmless the Krewe of Chaos Inc from any and all damage, injury or death which might occur to the undersigned or to the undersigned’s property in preparation for, during or immediately following any function held by or for the benefit of the Krewe of Chaos Inc and also from any and all liability whatsoever in regard thereto whether any cause of action may occur to you, your executor, administrator or assigns.  Applicant agrees to the above.
Electronic Signature	Applicant agrees that submitting this application online is the same as submitting via paper.