You may become a member of the World Domination Headquarters by printing a hard copy of this form, legibly typing or printing the required information, and remitting the signed and dated form along with applicable dues to:

World Domination Headquarters, 756 Rosecrans Ave., Manhattan Beach, CA 90266

Each member must submit a separate form.

Required Information

Name:

E-mail Address:

Telephone: Day                                              Evening

Home Address, City, State, Zip:

Mailing Address (if Different):

Emergency Contact - Name:

Telephone: Day                                              Evening
 

I have read and understood the World Domination Headquarters Membership Charter beginning April 27, 2007, and agree to its terms. I also agree to inform the World Domination Headquarters of any changes in the information I have provided in this Registration Form.

Dated:                       , 2007              Signature:

Optional Information

Occupation:

Date of Birth:

Expected Date of Arrival at 2007 Black Rock City Arts Festival:

Confidential Emergency Information:
Please provide any additional information which you feel necessary for the World Domination Headquarters to keep on file in the event of an emergency. Our goal is to be prepared. Anything can happen on the playa and time can be critical. This information will be kept confidential except as disclosure as deemed necessary for your welfare in an emergency.

* Information should include contact information for a member’s doctor, blood type, or special medical conditions such as drug allergies or diabetes which may be needed in the case of emergency medical treatment:*