USA Membership/Renewal Form

(Print-and-Mail)

Print out this form, fill it out, and mail this along with your payment to:

Unicycling Society of America, Inc.
PO Box 530518
Livonia, MI 48153-0518

Annual Dues

Individual: (US, Canada, Mexico)	$20 per year - includes subscription to quarterly newsletter, membership card, voting privileges, and National Unicycle Convention insurance.
Overseas:	$25 per year - (US Funds only)
Family:	$35 for members of the immediate family living at one address.

Please print all information                          Today's Date: _________

Name_________________________________________________ Birthdate:_____/_____/_____

Address__________________________________________________________________________
	      (Street)                                          (Apt Number)

_________________________________________________________________________________
                (City)                     (State)             (Zip)

Phone: (_____)________________ 

Club:___________________________ Skill Level 1 2 3 4 5 6 7 8 9 10

Family Membership: Add information for members of the 
immediate family residing at the same address

Name:___________________________________ Birthdate:_____/_____/_____  ___________
                                                    mon  day  year    Skill Level
Name:___________________________________ Birthdate:_____/_____/_____  ___________
                                                    mon  day  year    Skill Level
Name:___________________________________ Birthdate:_____/_____/_____  ___________
                                                    mon  day  year    Skill Level
Name:___________________________________ Birthdate:_____/_____/_____  ___________
                                                    mon  day  year    Skill Level

______ Please check here only if you do NOT want to be listed in the roster.

E-mail address:_________________________________________________________________


I learned about the USA Inc. through: __________________________________________


My interests include: ___________________________________________________________