IUCA Membership Form for Year 2010

Membership period is from January to December (Check appropriate box):

Individual membership, $50.00  (Single Individual)  

Family Membership, $100.00 (Husband, Wife and Children's under 18 years)

Senior Citizen (Single-65 Years and above), $25.00

Senior Citizen Couple (At least one member needs to be at or above 65 years of age), $50.00

Student (18 Years +), $25.00

Late fees after 1/31/2010, Regular membership fees + $10.00.

First Name: ___________________________________Last Name: ___________________________________

Occupation/Profession: ______________________________________

Spouse Name:

Children's Name:  1.     DOB: _______________

2.     DOB:_______________

3.     DOB:_______________

4.     DOB:_______________

Address: 

City: State: Zip Code:

Phone Number: Other Phone Number:

E-mail Addresses (Please provide all family members addresses):

E-mail 1: ________________________________________________

E-mail 2: _________________________________________________

E-mail 3: _______________________________________________

Print this form, fill it out completely and mail it with your check (Payable to IUCA) to:

IUCA, 231 Hawks Ridge Court, Columbus, GA 31904