Kristan Barclay
5149 Hunt Rd
Burlington, IA 52601

 For more information or questions….Call or Email
Kristan Barclay
 Phone 319-759-7617
MEMBERSHIP INFORMATION                                             (PLEASE PRINT CLEARLY)
Name:                                                                                             Birth Year:
Mailing Address:                                                                     Aprtment/Unit #
City:                                                     State:                             Zipcode:
Phone:                                                 E-Mail Address
Circle New, Renew or Life & CHECK MARK ON PROPER CATEGORY (office use only: Exp Date___________)
NEW / Renew        _________        WITH PUBLICATION $  30.00                              CK#_________
NEW / Renew  _________          NO PUBLICATION   $ 10.00
LIFE        _________         $1000 (includes plaque, patch, decals and monthly publication for life)
LIFE        _________         $200 (includes plaque, patch, decals with no monthly publication)
If paying by credit or debit card please fill out the information below
Master Card_______Visa _____    Discover_______            ______Credit _______Debit
Card Number__________________________________________CVV*__________Expire Date__________
Signature______________________________________           *CVV code is the 3 digit number on the back of your card
Iowa Trappers Association, Inc.

(Print Out)