MEMBERSHIP APPLICATION


Date _________ New Membership _________ Renewal __________


Name _______________________________________________________________


Address ____________________________________________________________


City _______________________________________________________________


State _______________ Zip Code (+4) __________________________


Telephone ______________________________


E-mail address ________________________________________


Individual $10 ______ Family $15 ______ Lifetime Individual $100 ______ Business $20 ______

Organization $20 ______


DONATION or MEMORIAL $ _________________

List names of honoree if desired

________________________________________________________________________________


MAIL TO:

SAPIC c/o Valerie Ogren
108 N. Oak St.
Jefferson, IA 50129