ISBA
INDIANA STRIPED BASS ASSOCIATION
MEMBERSHIP APPLICATION

$20.00 1 YEAR INDIVIDUAL MEMBERSHIP
$35.00 1 YEAR FAMILY MEMBERSHIP

PLEASE PRINT

DATE: ________________________

TYPE OF MEMBERSHIP:  INDIV_____ FAMILY______

LAST NAME: ________________________________________________________________________________________

FIRST NAME: ________________________________________________________________________________________

SPOUSE/CHILDREN NAMES: ___________________________________________________________________________

______________________________________________________________________________________________________
                                                            (FAMILY MEMBERSHIPS)                                                                   

ADDRESS

STREET: ______________________________________________________________________________________________

APT#: ______________ CITY: __________________________________ STATE: ___________ ZIP: ___________________

HOME PHONE: (_______) _____________________________________

CELL PHONE: (_______) ______________________________________

EMAIL ADDRESS: ______________________________________________________________________________________

MAIL THIS APPLICATION
WITH CHECK/MONEY ORDER TO:

ISBA
ATTN: MEMBERSHIP
P.O. BOX 568
MONTEZUMA, IN 47862