Church of the Machine

The Official International Symphony X Fan Club

Membership Application

Last Name:

First Name:

___ Male   ___ Female    

Birthdate - Month:         Day:          Year:    

E-mail address:

Street Address:

City/State:

Zip/Postal Code:

Country:

Paypal e-mail address (if different from the e-mail address given above):

Do you want a (yourname)@churchofthemachine.com e-mail address?  ___ yes   ___ no

If so, what name do you want to use? ______________________@churchofthemachine.com

*note*  Band member names & obscene names will not be accepted; names will be assigned at the discretion of the fan club staff. If the name you choose is already taken, you'll be asked to choose another name.

Desired e-mail password: ______________________ (must be at least 6 characters, and cannot be the same as the e-mail name)

Instructions on how to check this mail via webmail or POP3 will be mailed to you at your listed e-mail address and a copy enclosed in your membership package.

Fan club shirt size (M-3X): _____

Please send your PayPal payment first, then copy this application into an e-mail, fill it out, and send it with the subject “CotM Membership Application” to fanclub@churchofthemachine.com, and make sure that the name/e-mail address you used to send your PayPal payment is included here so we know which payment is whose. Your membership will not commence until this form is received; if payment was made by Paypal e-check, membership will commence once the transaction has cleared.

Thank you for your support of the band and the fan club!

Michael, Russ, Michael, Jason and Michael (Symphony X),

and Jax, CotM President/Founder