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