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

Domestic:	$15 per year - includes subscription to quarterly magazine, membership card, voting privileges, and National Unicycle Convention participation.
Mexico/Canada:	$20 per year - (US Funds only) Air Mail delivery
Overseas:	$25 per year - (US Funds only) Air Mail delivery
First class shipping:	$10 additional per year (in the US)

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

Additional Family Members: Add $5.00 per year (for
members of the immediate family of the member - residing
at the same address - same benefits as member listed above except no magazine)


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.


I learned about the USA Inc. through ___________________________________________

My interests include: ___________________________________________________________