2005 NIA MEMBERSHIP RENEWAL FORM

Note New Dues Schedule!

• Regular Membership--------------- $ 12.00
• Family Membership-----------------$ 12.00
• Junior Membership (under 18)---- $   5.00
• Club or Organization -------------- $ 12.00

(Check appropriate Class)  Regular_____ Family_____ Junior____ Club/Org.______                           

(Check Years of Payment)   Single year_____        Multi-year_____

Please Print

Name ________________________________________________NIA # (If Renewal)________

Address ______________________________________________________________________

City ____________________________________________State/Province ________________

Zip/Postal Code ___________( +4 )________Country (If Non U.S.) ____________________

Telephone Number ____________________E-Mail Address  __________________________

• Please include me in the Annual NIA/Crown Jewels Directory. ( Yes_____   No_____ )  

• Please include my Telephone Number.                                       ( Yes_____   No_____ )

• Please include my Email Address                                                    ( Yes_____   No_____ )

I Would like to Receive Drip Points in the Following Format.    Paper_____  Electronic_____            

      (Check Only One Choice) (Need E-Mail Address for Electronic)

Additional Family Members (Family Membership)

Signed ____________________________________________________

Date ______________________      Amount Enclosed   $ __________________