THANK YOU FOR YOUR INTEREST
IN BECOMING A CHECKYOURTOWN AMBASSADOR!

This registration is for our Premier Ambassador Plan
$20.00 annual fee

Simply complete the form below and process your Premier Membership Fee.

If you wish to view the Membership Agreement,
it is suggested that you do so before completeing this registration form 

__________________________

Confirmation and Issuance of Referral Code will be delivered
within 48 business hours of receipt

Referred By (Fan Number)	*
If not provided with a Referral Fan Number, please use 999999
First / Last Name	*
Contact: Email or Text	*
Email Address	*
Residence (town / state)	*
Date of Birth (required for legal age compliance)	*
I acknowledge and accept the Member Agreement	*	YES
Security Code	*