International Wild Waterfowl Association

INTERNATIONAL WILD WATERFOWL ASSOCIATION

MEMBERSHIP APPLICATION

I hereby apply for membership of the International Wild Waterfowl Association Inc. and subscribe to the purposes and objectives of the association to which I pledge my support.

NAME__________________________________________________________________

ADDRESS_______________________________________________________________

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PHONE H____________________________ B ________________________________

FAX_________________________ CELL______________________________

E-MAIL ________________________________________________________________

NEW_____________RENEW___________

( ) THIS MEMBERSHIP IS A GIFT:

RECIPIENT NAME:______________________________________________________

RECIPENT ADDRESS:___________________________________________________

_______________________________________________________________________

PHONE:___________________________ E-MAIL: _____________________________

INDIVIDUAL MEMBERSHIP $ 35.00 YR ___________________

ADD SPOUSE TO MEMBERSHIP $ 25.00 YR________________

INSTITUTIONAL MEMBERSHIP $ 100.00 YR _______________

LIFE MEMBERSHIP $ 1000.00 __________________

ADDITIONAL SPOUSE LIFE MEMBERSHIP $ 500.00 __________

PLEASE COMPLETE PAYMENT INFORMATION ON NEXT PAGE.

( ) CHECK ENCLOSED FOR $________________________________

( ) CHARGE MY VISA OR MASTERCARD $ ___________________

CARD: ( ) VISA ( ) MASTERCARD

NAME ON CARD_____________________________________________________________________

CARD NUMBER ____________________________________________ EXP DATE_______________

CARD HOLDER SIGNATURE__________________________________________________________

MAIL TO INTERNATIONAL WILD WATERFOWL ASSOCIATION.

C/0 JOHN NUCCITELLI

1111 HILLSBORO COVE CIRCLE

WEBSTER, NEW YORK 14580

PHONE 585-787-4043 FAX 585-787-4471