Widowed Friends Distance Membership

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phone:* Phone is Required

Your City & Province:* Your City & Province is Required

Age Group:* Age Group is Required

Spouse Name:* Spouse Name is Required

Year and Month of Death:* Year and Month of Death is Required

Proof of Loss Available Upon Request?*

Emergency Contact Name:* Emergency Contact Name is Required

Emergency Contact Phone:* Emergency Contact Phone is Required

How did you hear about us?:* How did you hear about us? is Required

I have read and agree to the Health & Safety Waiver*

I have read and agree to the Terms of Membership*

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Medium" or stronger

Select Payment Method

E Transfers

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Please send the full amount to widowedfriendsltd@gmail.com (auto deposit) Please allow 24-48hrs for manual payment processing. As soon as your payment is process you will be granted access to the membership site and you will receive the Welcome Email with instructions on how to login.

No val Please fix the errors above

Pay Widowed Friends

$100 / Year

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	Widowed Friends Distance Membership – Initial Payment $100 / Year	$100.00
	Total	$100.00

Widowed Friends Distance Membership – Initial Payment

$100 / Year

$100.00

Total

$100.00