NIA MEMBERSHIP APPLICATION


Submit In U.S.funds Payable to the NIA to:


NEW/RENEWAL FORM


Andrew Gibson Membership Director 5997 Springwater Road Dansville, NY 14437 Membership@NIA.org


Regular Membership----------------- $ 25.00 Family Membership------------------ $ 25.00 Junior Membership (under 18)----- $ 5.00 Club or Organization---------------- $ 50.00


============================================================= (Check appropriate Class) Regular_____ Family_____ Junior_____ Club/Org._____


(Check Years of Payment) Please Print


Single year_____ Multi-year_____


Name _________________________________________________________ NIA # (If Renewal)


_______________________________________________


Address _______________________________________________________ City __________________________________________________________ State/Province


________________________________________________


Zip/Postal Code __________________________(+4) __________________ _ Country (If Non U.S.) ______________________________________ ______ Telephone Number _______________________________________________ E-Mail Address __________________________________________________


Include me in the Annual NIA/Crown Jewels Directory? Please include my Telephone Number Please include my E-Mail Address


Yes_____ Yes_____


Yes___ No_____ No_____ No_____


I Would like to Receive Drip Points in the Following Format:. Paper_____ Electronic_____ (Check Only One Choice) (Need E-Mail Address for Electronic)


Additional Family Members residing at the same address: Name & NIA# (If Renewal)


1._____________________________________________________________ 2._____________________________________________________________ 3._____________________________________________________________ 4._____________________________________________________________


Signed ___________________________________ Date ______________ Amount Enclosed $ __________________


45


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