Become a Member Cremation Services and Membership: To become a member of the Cremation Society of the Quad Cities, please complete the following fields as much as possible or CLICK HERE TO DOWNLOAD AND PRINT A FORM. Before submitting you will be able to review all the information. Once received, our staff will prepare a certificate of membership, personalized wallet ID cards with our emergency contact numbers and a welcome letter. (Membership is not complete until we have all information.)Name:* First Middle Last Current Residence Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email:* Phone Number:*Member Date of Birth:* Member Location of Birth:* City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Last Name prior to first marriage:*Social Security NumberGender:*MaleFemaleOtherHighest Education:*Primary Occupation (Prior to retirement)*Type of Business/Industry*Ever in Armed Forces? (If yes, please forward a copy of military discharge papers.)*NoYesFather’s Name (as much as can be provided)* First Middle Last Name (Prior to first marriage) Mother’s Name (as much as can be provided)* First Middle Last Name (Prior to first marriage) Marital Status:*Spouse’s Information, if living First Middle Last Name (Prior to first marriage) Authorizing Agent:* First Last The authorizing agent is the individual who is to be in charge when death occurs.Relation to Member:*Phone Number:Email: Person Filling out this information*SelfSpouseAuthorizing AgentOtherName: First Last Phone:Additional InformationUse this space to provide us with any details you would like us to keep on record: Membership Fee: $49