Confirm & Submit Your Memebership
Please review the information below for accuracy. Click Here to return to the previous page. If the information is correct, press the "Process My Membership" button at the bottom of the page.
 

Confirm:  Membership (Location & Price):
Membership
 

Confirm:  Member Information:
First Name*:
Last Name*:
Shipping Address*:
Suite or Apartment:
City*:
State/Province*:
Country*:
Zip/Postal Code*:
Phone Number:
Fax Number:
Email Address*:
Would you like to be added to the
Mike Modano Fan Club e-newsletter list?
Gender:
Birthday: /
T-Shirt Size:
   

Confirm:  Credit Card Billing Information:
First Name*:
Last Name*:
Billing Address*:
Suite or Apartment:
City*:
State/Province*:
Country*:
Zip/Postal Code*:
Credit Card Type*:
Credit Card Number*:
Credit Card Expiration*: /
Additional email address for order confirmation (optional):
   
Note: To avoid multiple credit card charges, only press this button once.