Membership Form


Yes, I want to become a lifetime member.

$35 one-time fee

Prepayment Plan

(all payment plans include coverage throughout California)
One Time Payment $1,995
12 Month Payment Option (Zero finance charge)
12 monthly payments of $166.25 or more
24 Month Payment Option (Zero finance charge)
24 monthly payments of $83.13 or more



Optional Worldwide Plan $395
With this plan, we will arrange for the cremation of the deceased by a provider of our choice wherever the death occurs, anywhere in the world, and transfer the cremated remains to Cypress Lawn all at no extra charge.


Requested Final Disposition

Simple Sea Scattering (unescorted) Yes     No
Release to Family Yes     No
Placement at Cypress Lawn Yes     No
Send Remains to:
Name
Address
City
State
Zip Code
I am also Interested in:
Memorial Services Yes     No
Reception Center Yes     No
Traditional Funeral Services Yes     No



Personal Information

Name
(First, Middle Intial, Last Name)
AKA: Name
(First, Middle Intial, Last Name)
Sex
Date of Birth
State or Country of Birth
Social Security Number
Profession/Occupation
Years in Ocupation
Ethnic Background
If Hispanic please specify
Marital Status
Military Service
Branch
Service Number
Date of Enlistment
Date of Discharge


Next of Kin or Persons in Charge of Your Affairs

Name
(First, Middle Intial, Last, Name)
Relationship
Phone Number
Name
(First, Middle Intial, Last, Name)
Relationship
Phone Number
Do you have a Durable Power of Attorney (DPOA) for Health Care?
Please specify name of person with DPOA:
In California, a person with DPOA usually has primary right to make disposition decisions.


Billing Information

Name on Card
Card Type
Expiration Date /
CVV2   What is CVV2?
All orders are subject to
California state slaes tax.