MAIL TO:
Patty Kempf
3371 130th Street
Jamaica, IA 50128

For more information or questions…. Send email to Patty Kempf or call:
Home (641) 429-3102      Cell (641) 757-9733
MEMBERSHIP INFORMATION                                             (PLEASE PRINT CLEARLY)
Name:                                                                                             Birth Year:
Street Address:                                                                     Aprtment/Unit #
City:                                                     State:                             Zipcode:
County:
Phone:                                                 E-Mail Address
PLACE A CHECK MARK ON WHICHEVER CATEGORIES APPLY (office use only: Exp Date___________)
NEW        _________        WITH PUBLICATION $  20.00________                                        CK#_________
RENEW   _________          NO PUBLICATION   $ 10.00_________
LIFE        _________         $400 (includes plaque, patch and monthly publication for life)
LIFE        _________         $200 (includes plaque, patch with no monthly publication)
If paying by credit or debit card please fill out the information below
______Master Card_______Visa             ______Credit _______Debit
Card Number__________________________________________CVV*__________Expire Date__________
Signature______________________________________           *CVV code is the 3 digit number on the back of your card
MEMBERSHIP APPLICATION
Iowa Trappers Association, Inc.

(Print Out)